MEDICARE: DR. LAURA A GORDON PH.D.

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	101YM0800X	Mental Health Counselor	0505	NM

General Provider Information

NPI Number	:	1164434262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA A GORDON PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 16186
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88004-6186
Country	:	US
Telephone Number	:	505-649-9224
Fax Number	:

Provider Business Practice Location Address
First Line	:	1681 HICKORY LOOP
Second Line	:	STE. A
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-6587
Country	:	US
Telephone Number	:	505-649-9224
Fax Number	:

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

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	07/08/2007

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