Provider Demographics
NPI:1285149955
Name:GORDON, ALICIA (LCSW)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5464 CLUB CIR
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33415-1262
Mailing Address - Country:US
Mailing Address - Phone:561-252-7261
Mailing Address - Fax:
Practice Address - Street 1:132 CAROL CIR
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8128
Practice Address - Country:US
Practice Address - Phone:561-252-7261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities