Individual
COREY JAMES GORDER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LPCC
Contact information
Practice address
104 11TH ST W, STE. 4, BOTTINEAU, ND 58318-2005
(701) 201-0076
Mailing address
10275 SJULE RD, BOTTINEAU, ND 58318-7009
(701) 201-0076
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
569-12-15-06-190
ND
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
569-12-15-06-190
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
054517
—
ND
05
—
1225448798
—
ND
01
—
1588800882
BLUE CROSS/BLUE SHIELD
ND
Enumeration date
12/17/2008
Last updated
01/06/2016
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