Provider Demographics
NPI:1841079613
Name:GORDON, LAURA B
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:B
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 1:20 HERRELL RD
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-5527
Mailing Address - Country:US
Mailing Address - Phone:770-812-3928
Mailing Address - Fax:770-812-3989
Practice Address - Street 1:20 HERRELL RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-5527
Practice Address - Country:US
Practice Address - Phone:770-812-3928
Practice Address - Fax:770-812-3989
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN238583163W00000X, 163WP0807X, 163WP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health