Provider Demographics
NPI:1962116095
Name:GORDON, ANGELA JORI
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:JORI
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 1:1390 COLUMBIA AVE # 87
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-4743
Mailing Address - Country:US
Mailing Address - Phone:717-925-0533
Mailing Address - Fax:
Practice Address - Street 1:79 E MAIN ST # 303
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-1941
Practice Address - Country:US
Practice Address - Phone:717-925-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0011491101Y00000X
HIMHC-1022101Y00000X
PAPC015249101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor