Provider Demographics
NPI:1053659292
Name:GORDON, ROMAINE (CASAC)
Entity Type:Individual
Prefix:
First Name:ROMAINE
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4271 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5708
Mailing Address - Country:US
Mailing Address - Phone:516-520-6600
Mailing Address - Fax:516-520-6750
Practice Address - Street 1:4271 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5708
Practice Address - Country:US
Practice Address - Phone:516-520-6600
Practice Address - Fax:516-520-6750
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17613101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY17613OtherCERTAFIDE ALCOHOL AND SUBSTANCE COUNSELOR