Healthcare Provider Details

I. General information

NPI: 1790194942
Provider Name (Legal Business Name): MADELEINE BERNICE GORDON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 STEDMAN ST
JAMAICA PLAIN MA
02130-3618
US

IV. Provider business mailing address

8 STEDMAN ST
JAMAICA PLAIN MA
02130-3618
US

V. Phone/Fax

Practice location:
  • Phone: 617-915-3052
  • Fax: 617-675-9566
Mailing address:
  • Phone: 617-915-3052
  • Fax: 617-675-9566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number11073
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: