=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881138733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GORDON COUNSELING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2016
-----------------------------------------------------
Last Update Date | 05/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 E 5TH ST
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72653-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-425-2030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2563
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72654-2563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-469-4601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | CHRISTOPHER GORDON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 714-469-4601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | P1505049
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------