Healthcare Provider Details

I. General information

NPI: 1679759369
Provider Name (Legal Business Name): RICHARD GORDON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12439 SE 26TH AVENUE
MILWAUKIE OR
97222-8705
US

IV. Provider business mailing address

3325 N INTERSTATE AVE
PORTLAND OR
97227-1020
US

V. Phone/Fax

Practice location:
  • Phone: 360-241-6906
  • Fax:
Mailing address:
  • Phone: 503-249-3434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL3225
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: