Provider Demographics
NPI:1740358779
Name:GORDON, OFELIA G (LCSW, LMFT)
Entity type:Individual
Prefix:
First Name:OFELIA
Middle Name:G
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2784 N DECATUR RD
Mailing Address - Street 2:SUITE 145
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5903
Mailing Address - Country:US
Mailing Address - Phone:404-292-2664
Mailing Address - Fax:404-292-2835
Practice Address - Street 1:2784 N DECATUR RD
Practice Address - Street 2:SUITE 145
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5903
Practice Address - Country:US
Practice Address - Phone:404-292-2664
Practice Address - Fax:404-292-2835
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1521041C0700X
GA303106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBCBVMedicare UPIN
GA80BBCBVMedicare ID - Type Unspecified