Basic Information
| Provider Information | |||||||||
| NPI: | 1003296062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | SHAINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 980 SAINT CHARLES AVE NE | ||||||||
| Address2: | #3 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303064263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548951453 | ||||||||
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| Practice Location | |||||||||
| Address1: | 465 WINN WAY | ||||||||
| Address2: | 221 | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042923810 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 02/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CSW005234 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.