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General NPI Number Information
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NPI Number | 1437969466
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Entity Type | Individual
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Provider Name | LISA GORDON
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Gender | Female
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Dates
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Enumeration Date | 01/11/2025
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Last Update Date | 03/11/2025
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Provider Practice Location Address
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Address Line | 3646 MOUNT ELLIOTT ST
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City | DETROIT
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State | MI
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Zip | 48207-2311
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Country | US
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Telephone | 313-626-2400
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Fax |
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Provider Business Mailing Address
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Address Line | 15212 SALEM CT
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City | REDFORD
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State | MI
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Zip | 48239-3441
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Country | US
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Telephone | 248-325-7435
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 4704351548
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License Number State | MI
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