Provider Demographics
NPI:1508958489
Name:GORDON, MICHAEL A (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
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 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7000
Mailing Address - Fax:
Practice Address - Street 1:3650 STEVE REYNOLDS BLVD
Practice Address - Street 2:DEPARTMENT OF BEHAVIORAL HEALTH
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4506
Practice Address - Country:US
Practice Address - Phone:770-931-6012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002028103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
68BBGJZMedicare ID - Type Unspecified
S09667Medicare UPIN