Basic Information
| Provider Information | |||||||||
| NPI: | 1457647174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDY | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | GLORIA GORDY | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GORDY | ||||||||
| OtherFirstName: | GLORIA | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | GLORIA GORDY | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8401 LINK HILLS LOOP | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201553246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712482496 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8550 LEE HWY | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220311515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2011 | ||||||||
| LastUpdateDate: | 06/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0015000705 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TP2701X | 0015000705 | VA | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 163W00000X | 0001120029 | VA | N | Nursing Service Providers | Registered Nurse |
No ID Information.