MEDICARE: MS. CAROL ANNE GORDON LCSW

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	LCSW-4552	HI

General Provider Information

NPI Number	:	1619632254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL ANNE GORDON LCSW

Provider Business Mailing Address
First Line	:	500 UNIVERSITY AVE APT 303
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96826-4903
Country	:	US
Telephone Number	:	972-979-6001
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 UNIVERSITY AVE APT 303
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96826-4903
Country	:	US
Telephone Number	:	972-979-6001
Fax Number	:

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

Provider Enumeration Date	:	11/08/2021
Last Update Date	:	11/08/2021

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