Healthcare Provider Details

I. General information

NPI: 1952966905
Provider Name (Legal Business Name): SHELBY GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

7515 DELAWARE ST
RIVERSIDE CA
92504-3738
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-8000
  • Fax:
Mailing address:
  • Phone: 773-842-8877
  • 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: