MEDICARE: NICOLE GORDON MS, ADDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	ADDC.0000410	CO

General Provider Information

NPI Number	:	1376317297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE GORDON MS, ADDC

Provider Business Mailing Address
First Line	:	6430 BROOK PARK DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-1432
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1865 OLD RANCH RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80908-4528
Country	:	US
Telephone Number	:	719-528-3900
Fax Number	:

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

Provider Enumeration Date	:	11/10/2023
Last Update Date	:	11/10/2023

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