Provider Demographics
NPI:1235169335
Name:GORDON, NEAL J (EDD)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:J
Last Name:GORDON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 RUTGERS LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2911
Mailing Address - Country:US
Mailing Address - Phone:847-714-1164
Mailing Address - Fax:847-714-1165
Practice Address - Street 1:433 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-3688
Practice Address - Country:US
Practice Address - Phone:708-383-4671
Practice Address - Fax:847-714-1165
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-002067103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02272834OtherBLUECROSS PREFERRED PROV.
IL978990Medicare ID - Type Unspecified