1497420228 NPI number — MS. CHARITY RUTH GORDON LPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497420228 NPI number — MS. CHARITY RUTH GORDON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
CHARITY
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1497420228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 HILLCREST DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-239-7521
Provider Business Mailing Address Fax Number:
662-234-3071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 STARR AVE
Provider Second Line Business Practice Location Address:
STE K
Provider Business Practice Location Address City Name:
STARKVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-340-5947
Provider Business Practice Location Address Fax Number:
662-236-3071
Provider Enumeration Date:
08/13/2021

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: 101YM0800X , with the licence number:  2875 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: P-0605 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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