Provider Demographics
NPI:1912503087
Name:GORDON, KIM JEAN
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:JEAN
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:JEAN
Other - Last Name:SHISH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:225 CEDAR HILL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-5900
Mailing Address - Country:US
Mailing Address - Phone:346-317-2925
Mailing Address - Fax:
Practice Address - Street 1:225 CEDAR HILL ST STE 200
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-5900
Practice Address - Country:US
Practice Address - Phone:346-317-2925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA40134581OtherDRIVER LICENSES