Individual
KENRIC GLENN GORDON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMSW
Contact information
Practice address
210 W BURNSIDE AVE STE A, CHUBBUCK, ID 83202-4916
(208) 238-9000
Mailing address
210 W BURNSIDE AVE STE A, CHUBBUCK, ID 83202-4916
(208) 238-9000
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
LMSW-39661
ID
Other
Enumeration date
05/28/2020
Last updated
05/28/2020
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