Provider Demographics
NPI:1295367019
Name:ELLEN J GORDON LICENSED MASTER SOCIAL WORKER PC
Entity Type:Organization
Organization Name:ELLEN J GORDON LICENSED MASTER SOCIAL WORKER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-649-6278
Mailing Address - Street 1:507 EMPIRE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-3306
Mailing Address - Country:US
Mailing Address - Phone:631-649-6278
Mailing Address - Fax:
Practice Address - Street 1:8 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3337
Practice Address - Country:US
Practice Address - Phone:631-736-7707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-10
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty