MEDICARE: DANIEL M GORDON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PS 006922 L	PA

General Provider Information

NPI Number	:	1376706622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL M GORDON PHD

Provider Business Mailing Address
First Line	:	1518 WALNUT ST STE 1202
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-3407
Country	:	US
Telephone Number	:	215-735-3540
Fax Number	:

Provider Business Practice Location Address
First Line	:	1518 WALNUT ST STE 1202
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-3407
Country	:	US
Telephone Number	:	215-735-3540
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	07/08/2008

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