Healthcare Provider Details

I. General information

NPI: 1740934181
Provider Name (Legal Business Name): MICHELLE GORDEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4229 LAFAYETTE CENTER DR STE 1300
CHANTILLY VA
20151-1260
US

IV. Provider business mailing address

4229 LAFAYETTE CENTER DR STE 1300
CHANTILLY VA
20151-1260
US

V. Phone/Fax

Practice location:
  • Phone: 703-682-8215
  • Fax:
Mailing address:
  • Phone: 703-682-8215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701012166
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704013707
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: