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General NPI Number Information
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NPI Number | 1790194942
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Entity Type | Individual
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Provider Name | MADELEINE BERNICE GORDON PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 08/12/2014
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Last Update Date | 05/10/2021
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Provider Practice Location Address
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Address Line | 8 STEDMAN ST
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City | JAMAICA PLAIN
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State | MA
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Zip | 02130-3618
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Country | US
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Telephone | 617-915-3052
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Fax | 617-675-9566
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Provider Business Mailing Address
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Address Line | 8 STEDMAN ST
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City | JAMAICA PLAIN
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State | MA
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Zip | 02130-3618
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Country | US
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Telephone | 617-915-3052
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Fax | 617-675-9566
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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 | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 11073
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License Number State | MA
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