Healthcare Provider Details

I. General information

NPI: 1366193609
Provider Name (Legal Business Name): TITO TERRELL GORDON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: OTO TERRELL GORDON APC

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 WHEELER RD STE 365
AUGUSTA GA
30909-6549
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 706-432-6866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC016394
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: