Provider Demographics
NPI:1669696365
Name:GORDON, MITCHELL (PHD, ABPP)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2827 RIDGEFIELD CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5870
Mailing Address - Country:US
Mailing Address - Phone:786-506-9934
Mailing Address - Fax:
Practice Address - Street 1:2827 RIDGEFIELD CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5870
Practice Address - Country:US
Practice Address - Phone:786-506-9934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2241103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical