Provider Demographics
NPI:1508317363
Name:GORDON, THOMAS W
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:W
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:W
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW, CASAC-T
Mailing Address - Street 1:249 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508
Mailing Address - Country:US
Mailing Address - Phone:845-756-2366
Mailing Address - Fax:
Practice Address - Street 1:107 MINERAL SPRINGS RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND MILLS
Practice Address - State:NY
Practice Address - Zip Code:10930-6228
Practice Address - Country:US
Practice Address - Phone:914-924-1598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9258350101YA0400X
NY32584101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)