Provider Demographics
NPI:1679116669
Name:GORDON, AMY ELISABETH (LPCC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELISABETH
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 MARQUETTE AVE NW
Mailing Address - Street 2:UNIT 8
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1981
Mailing Address - Country:US
Mailing Address - Phone:505-409-5406
Mailing Address - Fax:
Practice Address - Street 1:811 MARQUETTE AVE NW
Practice Address - Street 2:UNIT 8
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1981
Practice Address - Country:US
Practice Address - Phone:505-409-5406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0206531101YM0800X
NMCCMH0222831101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM27134849Medicaid