Provider Demographics
NPI:1457966095
Name:GORDON, CLINTON SR (CIT)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:GORDON
Suffix:SR
Gender:M
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 OUACHITA AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-8513
Mailing Address - Country:US
Mailing Address - Phone:318-322-4770
Mailing Address - Fax:318-582-5096
Practice Address - Street 1:216 OUACHITA AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-8513
Practice Address - Country:US
Practice Address - Phone:318-322-4770
Practice Address - Fax:318-582-5096
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5184171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator