Provider Demographics
NPI:1871895250
Name:GORDON, LISA (LCPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:1925 GREENSPRING DR
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4128
Mailing Address - Country:US
Mailing Address - Phone:410-453-9553
Mailing Address - Fax:443-612-1488
Practice Address - Street 1:2225 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5778
Practice Address - Country:US
Practice Address - Phone:410-366-4360
Practice Address - Fax:410-366-4134
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MDLC3402101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health