Provider Demographics
NPI:1083905707
Name:GORDON, BRUCE R (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270-26TH STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402
Mailing Address - Country:US
Mailing Address - Phone:310-451-4442
Mailing Address - Fax:310-451-5674
Practice Address - Street 1:270-26TH ST.
Practice Address - Street 2:SUITE 202
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402
Practice Address - Country:US
Practice Address - Phone:310-457-4442
Practice Address - Fax:310-451-5674
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY.757103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical