Provider Demographics
NPI:1669871364
Name:GORDON, MALLORY MARGRET (LLP)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:MARGRET
Last Name:GORDON
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:MS
Other - First Name:MALLORY
Other - Middle Name:MARGRET
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLLP
Mailing Address - Street 1:19900 E. 10 MILE RD.
Mailing Address - Street 2:STE. 102
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080
Mailing Address - Country:US
Mailing Address - Phone:586-776-3366
Mailing Address - Fax:586-776-3369
Practice Address - Street 1:19900 E. 10 MILE RD.
Practice Address - Street 2:STE. 102
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-776-3366
Practice Address - Fax:586-776-3369
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL417827103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical