Healthcare Provider Details

I. General information

NPI: 1477692937
Provider Name (Legal Business Name): DIANE GORDON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6709 BERKSHIRE DR
TEMPLE HILLS MD
20748-4060
US

IV. Provider business mailing address

6709 BERKSHIRE DR
TEMPLE HILLS MD
20748-4060
US

V. Phone/Fax

Practice location:
  • Phone: 313-608-5307
  • Fax:
Mailing address:
  • Phone: 313-608-5307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC200001959
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29535
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200001959
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008521
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: