Healthcare Provider Details

I. General information

NPI: 1417455452
Provider Name (Legal Business Name): EITAN M GORDON ED.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 N GRANT ST
LEBANON IN
46052-1242
US

IV. Provider business mailing address

1810 N GRANT ST
LEBANON IN
46052-1242
US

V. Phone/Fax

Practice location:
  • Phone: 773-742-2487
  • Fax:
Mailing address:
  • Phone: 765-483-3090
  • Fax: 765-483-3087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10283464
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: