Provider Demographics
NPI:1720071921
Name:GORDON, MICHELE M (LICSW LMFT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:GORDON
Suffix:
Gender:F
Credentials:LICSW LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8144 S DOWLING LAKE RD W
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880
Mailing Address - Country:US
Mailing Address - Phone:715-399-3045
Mailing Address - Fax:
Practice Address - Street 1:8 N 2ND AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2102
Practice Address - Country:US
Practice Address - Phone:218-625-0188
Practice Address - Fax:218-625-0188
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11333104100000X
MN764106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist