Healthcare Provider Details

I. General information

NPI: 1508958489
Provider Name (Legal Business Name): MICHAEL A GORDON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 01/13/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 STEVE REYNOLDS BLVD DEPARTMENT OF BEHAVIORAL HEALTH
DULUTH GA
30096-4506
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 770-931-6012
  • Fax:
Mailing address:
  • Phone: 404-364-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY002028
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: