Provider Demographics
NPI:1912664939
Name:GORDON FELSENFELD, MALLORIE LAURA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MALLORIE
Middle Name:LAURA
Last Name:GORDON FELSENFELD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MALLORIE
Other - Middle Name:LAURA
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:11550 OLD GEORGETOWN RD APT 914
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2858
Mailing Address - Country:US
Mailing Address - Phone:917-882-8724
Mailing Address - Fax:
Practice Address - Street 1:10 CENTER DR RM 1C244
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-0004
Practice Address - Country:US
Practice Address - Phone:240-760-6538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003640103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical