Provider Demographics
NPI:1255825279
Name:GORDON, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ELA AVE
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2509
Mailing Address - Country:US
Mailing Address - Phone:603-404-0528
Mailing Address - Fax:
Practice Address - Street 1:1501 MAIN ST STE 30
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-4700
Practice Address - Country:US
Practice Address - Phone:508-851-7930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst