Provider Demographics
NPI:1912094582
Name:GORDON, VILMA MARTINEZ (LCSW)
Entity Type:Individual
Prefix:
First Name:VILMA
Middle Name:MARTINEZ
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 1:1241 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10474-5336
Mailing Address - Country:US
Mailing Address - Phone:718-378-6500
Mailing Address - Fax:718-993-0647
Practice Address - Street 1:651 ACADEMY ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-5003
Practice Address - Country:US
Practice Address - Phone:212-942-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0715681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNN9111Medicare PIN