Provider Demographics
NPI:1912531005
Name:GORDON, BOBBI BURNS (LPC)
Entity Type:Individual
Prefix:MRS
First Name:BOBBI
Middle Name:BURNS
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPC
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 3879
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39603-7879
Mailing Address - Country:US
Mailing Address - Phone:601-822-2286
Mailing Address - Fax:601-822-2296
Practice Address - Street 1:212 S WHITWORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601
Practice Address - Country:US
Practice Address - Phone:601-822-2286
Practice Address - Fax:601-822-2296
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2387101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health