MEDICARE: VIRGINIA KLEIN GORDON MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149002571	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	671245	OTHER	IL	BC/BS
2	2817317	OTHER	IL	AETNA
3	1935588	OTHER	IL	FIRST HEALTH

General Provider Information

NPI Number	:	1013918465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA KLEIN GORDON MSW

Provider Business Mailing Address
First Line	:	PO BOX 813
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-0813
Country	:	US
Telephone Number	:	847-433-5133
Fax Number	:

Provider Business Practice Location Address
First Line	:	464 CENTRAL AVE
Second Line	:
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-3040
Country	:	US
Telephone Number	:	847-433-5133
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	11/22/2014

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