Provider Demographics
NPI:1003875246
Name:GORDON, ELSIE MANAGBANAG (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELSIE
Middle Name:MANAGBANAG
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13-15 E DEER PARK DR
Mailing Address - Street 2:STE 103D
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2082
Mailing Address - Country:US
Mailing Address - Phone:240-686-6885
Mailing Address - Fax:240-686-6886
Practice Address - Street 1:13-15 E DEER PARK DR
Practice Address - Street 2:STE 103D
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2082
Practice Address - Country:US
Practice Address - Phone:240-686-6885
Practice Address - Fax:240-686-6886
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04451103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1721301Medicaid