Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003217514 |
---|---|
Provider Name | Kelly Gordon |
First Address | Orchard Park, NY 14127-2600 |
Second Address | Buffalo, NY 14209-1912 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2014 |
Last Update Date | 16/09/2014 |