Provider Demographics
NPI:1831602085
Name:GORDON, RAQUEL W (PHD)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:W
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16612 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3526
Mailing Address - Country:US
Mailing Address - Phone:301-356-6698
Mailing Address - Fax:
Practice Address - Street 1:1053 BUCHANAN ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2712
Practice Address - Country:US
Practice Address - Phone:202-854-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03284103T00000X
DCPSY1877103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist