Provider Demographics
NPI:1669879185
Name:RUSSELL-GORDON, PATIENCE (LPC-I)
Entity type:Individual
Prefix:
First Name:PATIENCE
Middle Name:
Last Name:RUSSELL-GORDON
Suffix:
Gender:F
Credentials:LPC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 HARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-4124
Mailing Address - Country:US
Mailing Address - Phone:843-592-0510
Mailing Address - Fax:
Practice Address - Street 1:609 CARTERET ST
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5003
Practice Address - Country:US
Practice Address - Phone:843-592-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5909101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional