Healthcare Provider Details

I. General information

NPI: 1336882315
Provider Name (Legal Business Name): TREVENE GORDON M.A, LPC, CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11923 CENTRE ST STE C
CHESTER VA
23831-1702
US

IV. Provider business mailing address

3200 RANSOM HILLS RD
NORTH CHESTERFIELD VA
23237-3571
US

V. Phone/Fax

Practice location:
  • Phone: 804-502-3723
  • Fax:
Mailing address:
  • Phone: 804-502-3723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710103698
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0701013512
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701013512
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701013512
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: