Provider Demographics
NPI:1780946947
Name:GORDON, MISTY S (MA)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:S
Last Name:GORDON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9541 KINGS PARADE BLVD
Mailing Address - Street 2:APT 307
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-5685
Mailing Address - Country:US
Mailing Address - Phone:678-592-8253
Mailing Address - Fax:
Practice Address - Street 1:363 CHURCH ST N
Practice Address - Street 2:SUITE 200
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4589
Practice Address - Country:US
Practice Address - Phone:704-262-1320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health