Provider Demographics
NPI:1457062630
Name:GORDON, NECHELLE
Entity Type:Individual
Prefix:
First Name:NECHELLE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 W MEMORIAL DR.
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313
Mailing Address - Country:US
Mailing Address - Phone:912-707-0657
Mailing Address - Fax:
Practice Address - Street 1:345 W MEMORIAL DR.
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-6737
Practice Address - Country:US
Practice Address - Phone:912-707-0657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007352101YP2500X
GALPC013445101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty