Healthcare Provider Details

I. General information

NPI: 1376784363
Provider Name (Legal Business Name): WILLIAM MICHAEL GORDON B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2009
Last Update Date: 03/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 THE CITY DR S # 2090
ORANGE CA
92868-3205
US

IV. Provider business mailing address

405 W 5TH ST # 590
SANTA ANA CA
92701-4599
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-6719
  • Fax: 714-935-8112
Mailing address:
  • Phone: 714-834-5015
  • Fax: 714-834-4595

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: