Provider Demographics
NPI:1669180873
Name:GORDON, KRISSA (CRC, LAC)
Entity type:Individual
Prefix:
First Name:KRISSA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:CRC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ALDERSGATE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6676
Mailing Address - Country:US
Mailing Address - Phone:501-661-0720
Mailing Address - Fax:
Practice Address - Street 1:17371 N HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:MOUNTAINBURG
Practice Address - State:AR
Practice Address - Zip Code:72946-3615
Practice Address - Country:US
Practice Address - Phone:479-790-3915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2201013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health