Provider Demographics
NPI:1972832756
Name:GORDON, DOUGLAS (LMSW)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 BROADWAY
Mailing Address - Street 2:APT. 6F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-4935
Mailing Address - Country:US
Mailing Address - Phone:212-677-7999
Mailing Address - Fax:
Practice Address - Street 1:743-749 EAST 9TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009
Practice Address - Country:US
Practice Address - Phone:212-677-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP728761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical