Provider Demographics
NPI:1700275237
Name:GORDON, KAREEN MARIE
Entity Type:Individual
Prefix:
First Name:KAREEN
Middle Name:MARIE
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 1:2195 INDIAN SHOALS DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7711
Mailing Address - Country:US
Mailing Address - Phone:917-515-5611
Mailing Address - Fax:
Practice Address - Street 1:2195 INDIAN SHOALS DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7711
Practice Address - Country:US
Practice Address - Phone:917-515-5611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator