Provider Demographics
NPI:1780732107
Name:GORDON, LISA G (LCSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:G
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6800 BACKLICK RD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-3070
Mailing Address - Country:US
Mailing Address - Phone:703-921-0692
Mailing Address - Fax:703-921-0637
Practice Address - Street 1:6800 BACKLICK RD
Practice Address - Street 2:SUITE #202
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-3070
Practice Address - Country:US
Practice Address - Phone:703-921-0692
Practice Address - Fax:703-921-0637
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904003348104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
268559OtherMDIPA
268559OtherOPTIMUM CHOICE
104300OtherUNITED HEALTH CARE
282455OtherAETNA
IP282455OtherMAGELLAN BEHAVIORAL HEALT
126464OtherHEALTHNET FEDERAL SERVICE
126464OtherVALUE OPTIONS
182922OtherANTHEM HEALTHKEEPERS
268559OtherALLIANCE
268559OtherMAMSI
323386OtherMHN
1550330001OtherGREAT WEST HEALTHCARE
2037724OtherCIGNA
4294OtherBCBS