Healthcare Provider Details

I. General information

NPI: 1649881533
Provider Name (Legal Business Name): MADELEINE GORDON, PSY.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
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 TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MADELEINE BERNICE GORDON
Title or Position: CLINICAL PSYCHOLOGIST/OWNER
Credential: PSY.D.
Phone: 617-915-3052