Provider Demographics
NPI:1932244662
Name:GORDON, PETER MICHAEL (MA - MFT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:MICHAEL
Last Name:GORDON
Suffix:
Gender:M
Credentials:MA - MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 E COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-2606
Mailing Address - Country:US
Mailing Address - Phone:562-826-9009
Mailing Address - Fax:
Practice Address - Street 1:4030 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-1502
Practice Address - Country:US
Practice Address - Phone:562-826-9009
Practice Address - Fax:562-987-3538
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39863101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health