Healthcare Provider Details

I. General information

NPI: 1285677989
Provider Name (Legal Business Name): ROBERT HARRISON GORDON JR. LCSW, M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD HUNTER HOLMES MCGUIRE VAMC
RICHMOND VA
23249-0001
US

IV. Provider business mailing address

44 EDGEWATER DR
PALMYRA VA
22963-3362
US

V. Phone/Fax

Practice location:
  • Phone: 434-963-2335
  • Fax:
Mailing address:
  • Phone: 434-589-3076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW004584L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: