=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942328588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDAN KELLEY LMSW-ACP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6387B CAMP BOWIE BLVD # 156
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-732-4225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6387B CAMP BOWIE BLVD # 156
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-732-4225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S00473
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------