=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215431333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D GORDON & ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2018
-----------------------------------------------------
Last Update Date | 03/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 E 53RD ST STE 1009
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-4547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-566-1702
-----------------------------------------------------
Fax | 847-423-6986
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 E 53RD ST STE 1009
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-4547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-566-1702
-----------------------------------------------------
Fax | 847-423-6986
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL GORDON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 312-566-1702
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149015415
-----------------------------------------------------
License Number State |
-----------------------------------------------------