Provider Demographics
NPI:1073022646
Name:GORDON, LAURA J (PSYD, MACAGS)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:J
Last Name:GORDON
Suffix:
Gender:F
Credentials:PSYD, MACAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 BEACH 118TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2036
Mailing Address - Country:US
Mailing Address - Phone:917-974-1312
Mailing Address - Fax:
Practice Address - Street 1:44 COURT ST STE 800
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4414
Practice Address - Country:US
Practice Address - Phone:718-855-1312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA500149103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool