Provider Demographics
NPI:1366571861
Name:GORDON, LUPE MANUELA
Entity type:Individual
Prefix:MS
First Name:LUPE
Middle Name:MANUELA
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 ANDERWOOD CT APT F
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-1740
Mailing Address - Country:US
Mailing Address - Phone:562-756-0906
Mailing Address - Fax:
Practice Address - Street 1:510 S 2ND AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3017
Practice Address - Country:US
Practice Address - Phone:626-974-8122
Practice Address - Fax:626-974-8198
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health