MEDICARE: TITO TERRELL GORDON LPC

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	101YP2500X	Professional Counselor	LPC016394	GA

General Provider Information

NPI Number	:	1366193609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TITO TERRELL GORDON LPC

Provider Business Mailing Address
First Line	:	4800 N SCOTTSDALE RD STE 2500
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85251-7630
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3633 WHEELER RD STE 365
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-6549
Country	:	US
Telephone Number	:	706-432-6866
Fax Number	:

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

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	05/27/2026

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