Provider Demographics
NPI:1134486426
Name:GORDON, SHANNON F (LICSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:F
Last Name:GORDON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 LAKE AVE N
Mailing Address - Street 2:UMASS MEMORIAL MEDICAL CENTER, PSYCHIATRY
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:774-442-2671
Mailing Address - Fax:774-442-5303
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:UMASS MEMORIAL MEDICAL CENTER, PSYCHIATRY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-442-2671
Practice Address - Fax:774-442-5303
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1163661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical