Provider Demographics
NPI:1104384098
Name:GORDON, ELIZA LEE (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:LEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1734 CLARKSON RD # 1122
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4976
Mailing Address - Country:US
Mailing Address - Phone:801-683-9068
Mailing Address - Fax:
Practice Address - Street 1:15480 ELK RIDGE LN
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5313
Practice Address - Country:US
Practice Address - Phone:801-683-9068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-09
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022012232103TH0004X, 103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth