Healthcare Provider Details

I. General information

NPI: 1073753349
Provider Name (Legal Business Name): DEIDRE MICHELLE GORDON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3841B SANDSTONE PL SE
ALBUQUERQUE NM
87116-3015
US

IV. Provider business mailing address

3841B SANDSTONE PL SE
ALBUQUERQUE NM
87116-3015
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-7803
  • Fax:
Mailing address:
  • Phone: 505-293-0115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0120411
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: