1780732107 NPI number — MS. LISA G GORDON LCSW

Table of content: MS. LISA G GORDON LCSW (NPI 1780732107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780732107 NPI number — MS. LISA G GORDON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
LISA
Provider Middle Name:
G
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780732107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6800 BACKLICK RD
Provider Second Line Business Mailing Address:
SUITE #202
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22150-3070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-921-0692
Provider Business Mailing Address Fax Number:
703-921-0637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6800 BACKLICK RD
Provider Second Line Business Practice Location Address:
SUITE #202
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22150-3070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-921-0692
Provider Business Practice Location Address Fax Number:
703-921-0637
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  0904003348 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 268559 . This is a "MDIPA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 268559 . This is a "OPTIMUM CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 104300 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 282455 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: IP282455 . This is a "MAGELLAN BEHAVIORAL HEALT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 126464 . This is a "HEALTHNET FEDERAL SERVICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 126464 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 182922 . This is a "ANTHEM HEALTHKEEPERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 268559 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 268559 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 323386 . This is a "MHN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1550330001 . This is a "GREAT WEST HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2037724 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4294 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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