Provider Demographics
NPI:1083920474
Name:GORDON, TIMOTHY DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DAVID
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:PO BOX 1630
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28370-1630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4102 BEN FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2140
Practice Address - Country:US
Practice Address - Phone:919-972-7700
Practice Address - Fax:877-256-8588
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011014431103T00000X
NC4784103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist