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General NPI Number Information
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NPI Number | 1518071117
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Entity Type | Individual
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Provider Name | TYRONE M GORDON RCSWI
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Gender | Male
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Dates
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Enumeration Date | 08/19/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 1955 US HIGHWAY 1 S SUITE C-2
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-3708
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Country | US
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Telephone | 904-825-5048
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Fax | 904-825-6824
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Provider Business Mailing Address
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Address Line | 1955 US HIGHWAY 1 S SUITE C-2
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-3708
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Country | US
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Telephone | 904-825-5048
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Fax | 904-825-6824
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | ISW3754
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License Number State | FL
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