Provider Demographics
NPI:1144397894
Name:GORDON, EMILY W (PSYD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:W
Last Name:GORDON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MILL ST
Mailing Address - Street 2:EAST HOUSE-ART
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1041
Mailing Address - Country:US
Mailing Address - Phone:617-855-2857
Mailing Address - Fax:
Practice Address - Street 1:1330 BEACON ST
Practice Address - Street 2:SUITE 324
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3282
Practice Address - Country:US
Practice Address - Phone:617-278-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7995103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW10498OtherBCBS
MAW51060Medicare ID - Type Unspecified