Provider Demographics
NPI:1366513012
Name:GORDON, KRYSTAL MI'CHAL (LCSW)
Entity type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:MI'CHAL
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:PO BOX 3044
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90711-3044
Mailing Address - Country:US
Mailing Address - Phone:310-885-2117
Mailing Address - Fax:310-537-9653
Practice Address - Street 1:546 W COMPTON BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-3011
Practice Address - Country:US
Practice Address - Phone:310-885-2117
Practice Address - Fax:310-537-9653
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW20095225400000X
CALCS 297621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner