Provider Demographics
NPI:1225033384
Name:GORDON, ROBERT M (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
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 1:1259 S CEDAR CREST BLVD
Mailing Address - Street 2:STE 325
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6206
Mailing Address - Country:US
Mailing Address - Phone:610-821-1072
Mailing Address - Fax:610-821-1072
Practice Address - Street 1:1259 S CEDAR CREST BLVD
Practice Address - Street 2:STE 325
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6206
Practice Address - Country:US
Practice Address - Phone:610-821-1072
Practice Address - Fax:610-821-1072
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002387L103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X, 103TF0200X, 103TP0814X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA281529Medicare ID - Type UnspecifiedPSYCHOLOGIST