Provider Demographics
NPI:1477685030
Name:GORDON, TODD KENNETH
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:KENNETH
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3-3212 KUHIO HWY
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-1142
Mailing Address - Country:US
Mailing Address - Phone:808-274-3190
Mailing Address - Fax:808-274-3194
Practice Address - Street 1:3-3212 KUHIO HWY
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1142
Practice Address - Country:US
Practice Address - Phone:808-274-3190
Practice Address - Fax:808-274-3194
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539372-01Medicaid