Healthcare Provider Details

I. General information

NPI: 1699367987
Provider Name (Legal Business Name): ROBIN WILSON GORDON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 MAPLE ST STE 100
CARROLLTON GA
30117-3259
US

IV. Provider business mailing address

816 ROME ST
CARROLLTON GA
30117-2235
US

V. Phone/Fax

Practice location:
  • Phone: 770-467-3369
  • Fax:
Mailing address:
  • Phone: 770-467-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC013765
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: