Healthcare Provider Details

I. General information

NPI: 1366571861
Provider Name (Legal Business Name): MS. LUPE MANUELA GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 2ND AVE SUITE 7
COVINA CA
91723-3017
US

IV. Provider business mailing address

451 ANDERWOOD CT APT F
POMONA CA
91768-1740
US

V. Phone/Fax

Practice location:
  • Phone: 626-974-8122
  • Fax: 626-974-8198
Mailing address:
  • Phone: 562-756-0906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: