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General NPI Number Information
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NPI Number | 1295367019
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Entity Type | Organization
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Legal Business Name | ELLEN J GORDON LICENSED MASTER SOCIAL WORKER PC
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Dates
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Enumeration Date | 02/10/2020
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Last Update Date | 03/09/2022
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Provider Practice Location Address
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Address Line | 8 ROOSEVELT AVE
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-3337
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Country | US
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Telephone | 631-736-7707
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Fax |
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Provider Business Mailing Address
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Address Line | 507 EMPIRE AVE
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City | WEST BABYLON
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State | NY
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Zip | 11704-3306
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Country | US
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Telephone | 631-649-6278
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Fax |
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Authorized Official
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Title or Position | LCSW
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Name | ELLEN GORDON
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Credential |
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Telephone | 631-649-6278
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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