Provider Demographics
NPI:1790194942
Name:GORDON, MADELEINE BERNICE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MADELEINE
Middle Name:BERNICE
Last Name:GORDON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 STEDMAN ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3618
Mailing Address - Country:US
Mailing Address - Phone:617-915-3052
Mailing Address - Fax:617-675-9566
Practice Address - Street 1:8 STEDMAN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3618
Practice Address - Country:US
Practice Address - Phone:617-915-3052
Practice Address - Fax:617-675-9566
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0000X, 103TC2200X
MA11073103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent