Healthcare Provider Details

I. General information

NPI: 1750154712
Provider Name (Legal Business Name): NELLIE LORENE GORDON SWT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11156 CANAL RD STE A
CINCINNATI OH
45241-5816
US

IV. Provider business mailing address

1801 WATERMARK DR
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 513-772-6166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2504247-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2504247-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: