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General NPI Number Information
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NPI Number | 1902829682
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Entity Type | Individual
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Provider Name | MARIA WILLIS GORDON LISW, LICDC
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Gender | Female
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1930 FULTON RD NW SUITE 102
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City | CANTON
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State | OH
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Zip | 44709-3526
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Country | US
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Telephone | 330-430-9535
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Fax | 330-430-9534
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Provider Business Mailing Address
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Address Line | PO BOX 9444
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City | CANTON
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State | OH
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Zip | 44711-9444
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Country | US
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Telephone | 330-430-9535
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Fax | 330-430-9534
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | I5078
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License Number State | OH
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