Provider Demographics
NPI:1700369485
Name:GORDON, ELLEN MAE (MSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:MAE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-1962
Mailing Address - Country:US
Mailing Address - Phone:617-243-0211
Mailing Address - Fax:
Practice Address - Street 1:182 CHURCH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-1962
Practice Address - Country:US
Practice Address - Phone:617-243-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA102695104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty