Provider Demographics
NPI:1659855690
Name:LANG, GORDON ALAN (MSW)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:ALAN
Last Name:LANG
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:MR
Other - First Name:GORDON
Other - Middle Name:ALAN
Other - Last Name:LANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:14 MORTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2249
Mailing Address - Country:US
Mailing Address - Phone:617-821-2933
Mailing Address - Fax:
Practice Address - Street 1:14 MORTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2249
Practice Address - Country:US
Practice Address - Phone:617-821-2933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-15
Last Update Date:2018-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA113694-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool