1912921966 NPI number — MRS. LISA GREEN GORDON M.D.

Table of content: MRS. LISA GREEN GORDON M.D. (NPI 1912921966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912921966 NPI number — MRS. LISA GREEN GORDON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
LISA
Provider Middle Name:
GREEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREEN-PADEN
Provider Other First Name:
LISA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912921966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 W. PATRICK STREET, SUITE 100
Provider Second Line Business Mailing Address:
BEHAVIORAL HEALTH PARTNERS, INC.
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-662-3223
Provider Business Mailing Address Fax Number:
301-662-7921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
219 W. PATRICK STREET, SUITE 100
Provider Second Line Business Practice Location Address:
BEHAVIORAL HEALTH PARTNERS, INC.
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-662-3223
Provider Business Practice Location Address Fax Number:
301-662-7921
Provider Enumeration Date:
07/26/2006

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: 2084P0800X , with the licence number:  D0053537 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 211004100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".