Healthcare Provider Details

I. General information

NPI: 1104472935
Provider Name (Legal Business Name): ADAM J GORDON LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6363 DEZAVALA RD
SAN ANTONIO TX
78249
US

IV. Provider business mailing address

208 OAK HOLLOW DR
LA VERNIA TX
78121-9788
US

V. Phone/Fax

Practice location:
  • Phone: 210-399-4838
  • Fax:
Mailing address:
  • Phone: 254-717-8241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number67787
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: