Provider Demographics
NPI:1689760654
Name:GORDON, ALAN HOWARD (EDD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:HOWARD
Last Name:GORDON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WALPOLE ST
Mailing Address - Street 2:STE 6
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-3319
Mailing Address - Country:US
Mailing Address - Phone:781-769-1646
Mailing Address - Fax:781-769-4696
Practice Address - Street 1:45 WALPOLE ST
Practice Address - Street 2:STE 6
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3319
Practice Address - Country:US
Practice Address - Phone:781-769-1646
Practice Address - Fax:781-769-4696
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2572103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0520896Medicaid
MAW02873OtherBLUE CROSS BLUE SHIELD
MA109343OtherMAGELLAN BEHAVIORAL HEALT
MA719788OtherTUFTS HEALTH PLAN
MA0520896Medicaid