MEDICARE: KRISTEN GORDON MA, LPC INTERN

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	71842	TX

General Provider Information

NPI Number	:	1407271869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN GORDON MA, LPC INTERN

Provider Business Mailing Address
First Line	:	2053 OAK VIEW MDWS
Second Line	:
City	:	HUFFMAN
State	:	TX
Zip	:	77336-2706
Country	:	US
Telephone Number	:	281-324-1052
Fax Number	:

Provider Business Practice Location Address
First Line	:	9511 N HIGHWAY 146
Second Line	:
City	:	MONT BELVIEU
State	:	TX
Zip	:	77523-9677
Country	:	US
Telephone Number	:	281-576-2444
Fax Number	:	281-576-4506

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

Provider Enumeration Date	:	02/21/2014
Last Update Date	:	04/12/2019

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