=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255670287
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA B GORDON LCPC, CD(DONA)
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2013
-----------------------------------------------------
Last Update Date | 02/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 W FULLERTON AVE #305
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-304-6483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1350 W. FULLERTON #305
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-304-6483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.007445
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------