Healthcare Provider Details

I. General information

NPI: 1841918448
Provider Name (Legal Business Name): LAUREN GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 COHO ST STE 203
MADISON WI
53713-4521
US

IV. Provider business mailing address

302 GRAND CANYON DR APT 11
MADISON WI
53705-4263
US

V. Phone/Fax

Practice location:
  • Phone: 608-291-7033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11749125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: