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General NPI Number Information
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NPI Number | 1588800882
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Entity Type | Individual
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Provider Name | COREY JAMES GORDER LPCC
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Gender | Male
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Dates
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Enumeration Date | 12/17/2008
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Last Update Date | 01/06/2016
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Provider Practice Location Address
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Address Line | 104 11TH ST W STE. 4
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City | BOTTINEAU
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State | ND
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Zip | 58318-2005
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Country | US
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Telephone | 701-201-0076
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Fax |
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Provider Business Mailing Address
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Address Line | 10275 SJULE RD
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City | BOTTINEAU
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State | ND
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Zip | 58318-7009
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Country | US
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Telephone | 701-201-0076
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 569-12-15-06-190
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 569-12-15-06-190
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License Number State | ND
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