=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538920509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN ELAINE GORDON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2024
-----------------------------------------------------
Last Update Date | 01/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9405 CYPRESS LAKE DR STE 2
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33919-0909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-946-4131
-----------------------------------------------------
Fax | 239-936-3391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5319 CHIPPENDALE CIR W
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33919-2247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-699-4940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW31590
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------