MEDICARE: MS. SUSAN RIDDLE GORDON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW003185	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285678359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN RIDDLE GORDON LCSW

Provider Business Mailing Address
First Line	:	2402 TIFT AVE N
Second Line	:	SUITE 102
City	:	TIFTON
State	:	GA
Zip	:	31794-1883
Country	:	US
Telephone Number	:	229-392-6600
Fax Number	:	229-382-2181

Provider Business Practice Location Address
First Line	:	2402 TIFT AVE N
Second Line	:	SUITE 102
City	:	TIFTON
State	:	GA
Zip	:	31794-1883
Country	:	US
Telephone Number	:	229-392-6600
Fax Number	:	229-382-2181

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	12/02/2008

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