Healthcare Provider Details

I. General information

NPI: 1083920474
Provider Name (Legal Business Name): TIMOTHY DAVID GORDON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 BEN FRANKLIN BLVD
DURHAM NC
27704-2140
US

IV. Provider business mailing address

PO BOX 1630
PINEHURST NC
28370-1630
US

V. Phone/Fax

Practice location:
  • Phone: 919-972-7700
  • Fax: 877-256-8588
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2011014431
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4784
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: