Provider Demographics
NPI:1083906358
Name:GORDON, JULIAN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JULIAN
Middle Name:M
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 1:53 WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2947
Mailing Address - Country:US
Mailing Address - Phone:248-881-2060
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2139
Practice Address - Country:US
Practice Address - Phone:313-834-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6301005530103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist