Provider Demographics
NPI:1417111568
Name:GORDON, ROBERT HALL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HALL
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 1:1129 MACKLIND AVE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1440
Mailing Address - Country:US
Mailing Address - Phone:314-825-2161
Mailing Address - Fax:
Practice Address - Street 1:211 E 7TH ST STE 620
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-3218
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36046103T00000X
MO2007012472103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical