Healthcare Provider Details

I. General information

NPI: 1023273349
Provider Name (Legal Business Name): DAVID P. GORDON, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 W LAKE ST STE 304
MINNEAPOLIS MN
55408-6601
US

IV. Provider business mailing address

1516 W LAKE ST STE 304
MINNEAPOLIS MN
55408-6601
US

V. Phone/Fax

Practice location:
  • Phone: 612-281-7773
  • Fax:
Mailing address:
  • Phone: 612-281-7773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number01545
License Number StateMN

VIII. Authorized Official

Name: DAVID P. GORDON
Title or Position: CEO
Credential: LICSW
Phone: 612-281-7773