Provider Demographics
NPI:1003397704
Name:GORDON, SHACORA TAWANNA
Entity Type:Individual
Prefix:
First Name:SHACORA
Middle Name:TAWANNA
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BRIDGE ST APT 7B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1513
Mailing Address - Country:US
Mailing Address - Phone:475-449-4556
Mailing Address - Fax:
Practice Address - Street 1:2631 MERRICK RD STE 302
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5784
Practice Address - Country:US
Practice Address - Phone:516-590-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY103K00000XMedicaid