Healthcare Provider Details

I. General information

NPI: 1053222786
Provider Name (Legal Business Name): BENJAMIN ETHAN GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 COMMONWEALTH AVE
BOSTON MA
02134-3747
US

IV. Provider business mailing address

108 WINTHROP RD APT 2
BROOKLINE MA
02445-4585
US

V. Phone/Fax

Practice location:
  • Phone: 617-504-1284
  • Fax:
Mailing address:
  • Phone: 617-504-1284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: