Healthcare Provider Details

I. General information

NPI: 1033446083
Provider Name (Legal Business Name): LARRY GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 WASHINGTON ST
CONWAY NH
03818-6044
US

IV. Provider business mailing address

87 WASHINGTON ST
CONWAY NH
03818-6044
US

V. Phone/Fax

Practice location:
  • Phone: 603-447-3347
  • Fax: 603-447-1022
Mailing address:
  • Phone: 603-447-3347
  • Fax: 603-447-1022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier81263824
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: