Healthcare Provider Details

I. General information

NPI: 1649102856
Provider Name (Legal Business Name): TRACI L GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 SUWANEE DAM RD STE 450
SUWANEE GA
30024-8706
US

IV. Provider business mailing address

727 HAIRSTON CROSSING CT
STONE MOUNTAIN GA
30083-3431
US

V. Phone/Fax

Practice location:
  • Phone: 770-283-8386
  • Fax:
Mailing address:
  • Phone: 678-908-8077
  • 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: