Provider Demographics
NPI:1629197835
Name:GORDON, LINDA ARLINE (DSP)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:ARLINE
Last Name:GORDON
Suffix:
Gender:F
Credentials:DSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 UNION STREET
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6731
Mailing Address - Country:US
Mailing Address - Phone:207-338-1210
Mailing Address - Fax:
Practice Address - Street 1:108 UNION STREET
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6731
Practice Address - Country:US
Practice Address - Phone:207-338-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS1520320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities