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General NPI Number Information
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NPI Number | 1104384098
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Entity Type | Individual
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Provider Name | ELIZA LEE GORDON PHD
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Gender | Female
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Dates
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Enumeration Date | 03/09/2019
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Last Update Date | 09/21/2022
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Provider Practice Location Address
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Address Line | 15480 ELK RIDGE LN
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City | CHESTERFIELD
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State | MO
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Zip | 63017-5313
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Country | US
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Telephone | 801-683-9068
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Fax |
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Provider Business Mailing Address
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Address Line | 1734 CLARKSON RD # 1122
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City | CHESTERFIELD
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State | MO
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Zip | 63017-4976
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Country | US
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Telephone | 801-683-9068
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0004X
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Taxonomy Name | Health Psychologist
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License Number | 2022012232
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2022012232
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License Number State | MO
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