Provider Demographics
NPI:1649881533
Name:MADELEINE GORDON, PSY.D., LLC
Entity type:Organization
Organization Name:MADELEINE GORDON, PSY.D., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADELEINE
Authorized Official - Middle Name:BERNICE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:617-915-3052
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health