Provider Demographics
NPI:1760739718
Name:GORDON, AVIGAIL (MA)
Entity Type:Individual
Prefix:
First Name:AVIGAIL
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6940 108TH ST APT 6E
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3823
Mailing Address - Country:US
Mailing Address - Phone:718-544-0196
Mailing Address - Fax:
Practice Address - Street 1:34 W 139TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1508
Practice Address - Country:US
Practice Address - Phone:718-208-5367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist