Provider Demographics
NPI:1881351039
Name:GORDON, AUDREY NICOLE (LPC LCDC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:NICOLE
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPC LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748465
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8465
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:
Practice Address - Street 1:7979 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2657
Practice Address - Country:US
Practice Address - Phone:571-499-1064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15966101YA0400X
TX87094101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health