Provider Demographics
NPI:1821380015
Name:GORDON, MONIQUE G (LCSW)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:G
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1805
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1805
Mailing Address - Country:US
Mailing Address - Phone:207-631-4403
Mailing Address - Fax:
Practice Address - Street 1:3895 W RIVER RD
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:ME
Practice Address - Zip Code:04330-2434
Practice Address - Country:US
Practice Address - Phone:207-547-4464
Practice Address - Fax:207-547-4686
Is Sole Proprietor?:No
Enumeration Date:2011-05-06
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC135881041C0700X
MEMC126381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical