Provider Demographics
NPI:1033952288
Name:GORDON, KRISTIN DEWAILA (DBH, LSSYB, RMHCI)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:DEWAILA
Last Name:GORDON
Suffix:
Gender:F
Credentials:DBH, LSSYB, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32428 QUIET HARBOR AVE UNIT 203
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-8726
Mailing Address - Country:US
Mailing Address - Phone:850-346-6377
Mailing Address - Fax:
Practice Address - Street 1:32428 QUIET HARBOR AVE UNIT 203
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-8726
Practice Address - Country:US
Practice Address - Phone:850-346-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH25966101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional