Provider Demographics
NPI:1407815178
Name:GORDON, BARRY HALE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:HALE
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 GREEN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5725
Mailing Address - Country:US
Mailing Address - Phone:440-886-9655
Mailing Address - Fax:
Practice Address - Street 1:3601 GREEN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5725
Practice Address - Country:US
Practice Address - Phone:440-886-9655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2806103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000136466OtherANTHEM
OH265233OtherVALUEOPTIONS
OH4092054OtherAETNA
OH265233OtherVALUEOPTIONS