Provider Demographics
NPI:1457607467
Name:GORDON, SUELLEN MARIE (MS)
Entity type:Individual
Prefix:
First Name:SUELLEN
Middle Name:MARIE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4307
Mailing Address - Country:US
Mailing Address - Phone:631-692-9357
Mailing Address - Fax:
Practice Address - Street 1:241 BARTON AVE
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4307
Practice Address - Country:US
Practice Address - Phone:631-692-9357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist