Provider Demographics
NPI:1740278688
Name:GORDON, PHYLLIS ARLENE (MSSW)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ARLENE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:ARLENE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSW
Mailing Address - Street 1:PO BOX 1065
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-1065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N HOLTZCLAW AVE
Practice Address - Street 2:STE 100
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1242
Practice Address - Country:US
Practice Address - Phone:423-622-0500
Practice Address - Fax:423-622-0564
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW008821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3694920Medicaid
3694920Medicare ID - Type Unspecified