Provider Demographics
NPI:1932192762
Name:GORDON, EDNA D (LCSW)
Entity Type:Individual
Prefix:MS
First Name:EDNA
Middle Name:D
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:EDNA
Other - Middle Name:D
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:777 S PALM AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-7770
Mailing Address - Country:US
Mailing Address - Phone:941-955-2555
Mailing Address - Fax:
Practice Address - Street 1:777 S PALM AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-7770
Practice Address - Country:US
Practice Address - Phone:941-955-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW25991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3690Medicare ID - Type Unspecified
FLZ3690Medicare PIN