Healthcare Provider Details

I. General information

NPI: 1710635206
Provider Name (Legal Business Name): TRACY LEATRICE GORDON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 COUNTRY CLUB DR
STOCKBRIDGE GA
30281-7349
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 770-474-8400
  • Fax: 770-474-3738
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC24466
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904013773
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2795
License Number StateNH
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009359
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28899
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number095397
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW20113
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06041900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: