Provider Demographics
NPI:1699111815
Name:GORDON, CHARLIE RENEE (BHRS)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:RENEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 N HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-3270
Mailing Address - Country:US
Mailing Address - Phone:405-303-2735
Mailing Address - Fax:
Practice Address - Street 1:112 N HIGH ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2250
Practice Address - Country:US
Practice Address - Phone:580-298-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator