Healthcare Provider Details

I. General information

NPI: 1942306675
Provider Name (Legal Business Name): CLIFFORD I GORDON ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 BRIDGE WAY
PASCOAG RI
02859-3131
US

IV. Provider business mailing address

18 OLD CHIMNEY RD
BARRINGTON RI
02806-3243
US

V. Phone/Fax

Practice location:
  • Phone: 401-568-7661
  • Fax: 401-245-5762
Mailing address:
  • Phone: 401-247-2798
  • Fax: 401-245-5762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS00331
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: