Provider Demographics
NPI:1619197993
Name:GORDON, DAVID PAUL (MSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:PAUL
Last Name:GORDON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 W 50TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1307
Mailing Address - Country:US
Mailing Address - Phone:612-281-7773
Mailing Address - Fax:
Practice Address - Street 1:133 W 50TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1307
Practice Address - Country:US
Practice Address - Phone:612-281-7773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45-0463081102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN45-0463081OtherEMPLOYEE ID NUMBER