Provider Demographics
NPI:1790701571
Name:GORDON, MARTIN BLACKWELL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:BLACKWELL
Last Name:GORDON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 N COURTHOUSE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236-4069
Mailing Address - Country:US
Mailing Address - Phone:804-794-4482
Mailing Address - Fax:894-379-7578
Practice Address - Street 1:703 N COURTHOUSE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23236-4069
Practice Address - Country:US
Practice Address - Phone:804-794-4482
Practice Address - Fax:894-379-7578
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040022301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical