Provider Demographics
NPI:1982740429
Name:GORDETSKY, SHARON (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:
Last Name:GORDETSKY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6875
Mailing Address - Country:US
Mailing Address - Phone:617-277-5584
Mailing Address - Fax:617-277-5584
Practice Address - Street 1:1419 BEACON STREET
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:617-277-5584
Practice Address - Fax:617-277-5584
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1599103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW01937OtherBCBS
MA1899392Medicaid