Provider Demographics
NPI:1881945103
Name:GORDON, SARAH JOAN (LICSW)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:JOAN
Last Name:GORDON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 E. BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216
Mailing Address - Country:US
Mailing Address - Phone:503-239-8400
Mailing Address - Fax:503-239-8406
Practice Address - Street 1:1027 E BURNSIDE STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-1280
Practice Address - Country:US
Practice Address - Phone:503-239-8400
Practice Address - Fax:503-239-8406
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19093101YM0800X, 103K00000X, 1041C0700X
OR71561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA097725000Medicaid