Provider Demographics
NPI:1255683561
Name:GORDON, DESIREE MARTINEAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:MARTINEAY
Last Name:GORDON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:DEZIRE'
Other - Middle Name:MARTINEAY
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2370 W CLEVELAND AVE # 108-320
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-8742
Mailing Address - Country:US
Mailing Address - Phone:559-777-9439
Mailing Address - Fax:559-416-7091
Practice Address - Street 1:2370 W CLEVELAND AVE # 108-320
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-8742
Practice Address - Country:US
Practice Address - Phone:559-777-9439
Practice Address - Fax:559-416-7091
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARA897812101YA0400X
IL178.003764101YP2500X
IL17815103TA0400X
CAPSY28775103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)