Provider Demographics
NPI:1407024771
Name:GORDON, LISA BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:BETH
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:BETH
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:618 LIBRARY PLACE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2908
Mailing Address - Country:US
Mailing Address - Phone:847-733-4300
Mailing Address - Fax:847-733-0390
Practice Address - Street 1:618 LIBRARY PLACE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2908
Practice Address - Country:US
Practice Address - Phone:847-733-4300
Practice Address - Fax:847-733-0390
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6692103TC0700X
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU26622Medicaid