Healthcare Provider Details

I. General information

NPI: 1033939483
Provider Name (Legal Business Name): MATTHEW LUCAS GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 03/04/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 40TH ST STE 206
BALTIMORE MD
21211-2108
US

IV. Provider business mailing address

5104 YORK ROAD STUDENT LIFE- SETON 08B
BALTIMORE MD
21212
US

V. Phone/Fax

Practice location:
  • Phone: 410-842-6055
  • Fax:
Mailing address:
  • Phone: 470-833-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA01046
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA01046
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: