Provider Demographics
NPI:1164430229
Name:ST.MARY, GORDON ALEXANDER JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:ALEXANDER
Last Name:ST.MARY
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 ODESSA AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1219
Mailing Address - Country:US
Mailing Address - Phone:818-817-2391
Mailing Address - Fax:
Practice Address - Street 1:10929 SOUTH ST STE 202B
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-5368
Practice Address - Country:US
Practice Address - Phone:818-326-3816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17475103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical