Provider Demographics
NPI:1083216824
Name:GORDON, AVI
Entity Type:Individual
Prefix:
First Name:AVI
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 N 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7820 PETERS RD STE E100
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-4019
Practice Address - Country:US
Practice Address - Phone:954-546-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10944103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist