Provider Demographics
NPI:1467066480
Name:GORDON, OCTAVIA D
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:D
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 1:147 NORMAN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-5003
Mailing Address - Country:US
Mailing Address - Phone:413-846-0445
Mailing Address - Fax:
Practice Address - Street 1:80 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-4704
Practice Address - Country:US
Practice Address - Phone:413-846-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY10086OtherMEDICARE
MA1134107113Medicaid