Provider Demographics
NPI:1336882315
Name:GORDON, TREVENE (MA)
Entity Type:Individual
Prefix:MRS
First Name:TREVENE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 RANSOM HILLS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-3571
Mailing Address - Country:US
Mailing Address - Phone:804-502-3723
Mailing Address - Fax:
Practice Address - Street 1:3200 RANSOM HILLS RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23237-3571
Practice Address - Country:US
Practice Address - Phone:804-502-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013537101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional