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NPI Code Detail

MEDICARE: MR. JAMES BLAKELY GORDON MRC

MEDICARE: MR. JAMES BLAKELY GORDON MRC
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
1101YM0800XMental Health Counselor#4691SC

General Provider Information

NPI Number : 1669439352
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JAMES BLAKELY GORDON MRC
Provider Business Mailing Address
First Line : 1800 COLONIAL DRIVE
Second Line :
City : COLUMBIA
State : SC
Zip : 29203-2219
Country : US
Telephone Number : 803-898-1555
Fax Number : 803-898-2194
Provider Business Practice Location Address
First Line : 1821 PICKENS ST
Second Line :
City : COLUMBIA
State : SC
Zip : 29201-2630
Country : US
Telephone Number : 803-929-1234
Fax Number : 803-929-1247
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/27/2006
Last Update Date : 07/08/2007

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