Provider Demographics
NPI:1194937532
Name:GORDON-DAVIS, KAREN LEE (PHD, APRN,BC)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:LEE
Last Name:GORDON-DAVIS
Suffix:
Gender:F
Credentials:PHD, APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SULGRAVE AVE
Mailing Address - Street 2:206
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3654
Mailing Address - Country:US
Mailing Address - Phone:410-664-6700
Mailing Address - Fax:
Practice Address - Street 1:1501 SULGRAVE AVE
Practice Address - Street 2:206
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3654
Practice Address - Country:US
Practice Address - Phone:410-664-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X
MDR038816364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Not Answered364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCH2710001OtherBLUE CROSS
MDPN28OtherBLUE CROSS
MDPN28OtherBLUE CROSS
MD134RMedicare ID - Type Unspecified