Healthcare Provider Details

I. General information

NPI: 1366513012
Provider Name (Legal Business Name): KRYSTAL MI'CHAL GORDON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 W COMPTON BLVD
COMPTON CA
90220-3011
US

IV. Provider business mailing address

PO BOX 3044
LAKEWOOD CA
90711-3044
US

V. Phone/Fax

Practice location:
  • Phone: 310-885-2117
  • Fax: 310-537-9653
Mailing address:
  • Phone: 310-885-2117
  • Fax: 310-537-9653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberASW20095
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 29762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: