Healthcare Provider Details

I. General information

NPI: 1972635928
Provider Name (Legal Business Name): KAREN L GORDON MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 K ST
MODESTO CA
95354-1018
US

IV. Provider business mailing address

2812 KINGMAN CT
MODESTO CA
95355-8463
US

V. Phone/Fax

Practice location:
  • Phone: 209-523-4573
  • Fax:
Mailing address:
  • Phone: 209-550-5850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 41486
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: