Provider Demographics
NPI:1629779335
Name:GORDON, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
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 1:3945 CONNECTICUT AVE NW APT 309
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-3483
Mailing Address - Country:US
Mailing Address - Phone:301-356-4078
Mailing Address - Fax:
Practice Address - Street 1:3945 CONNECTICUT AVE NW APT 309
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-3483
Practice Address - Country:US
Practice Address - Phone:301-356-4078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC200001409101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health