MEDICARE: DIANE LYNN GORDON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R028275-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	285580P	OTHER	NY	HIP/EMBLEM HEALTH

General Provider Information

NPI Number	:	1316278385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE LYNN GORDON LCSW

Provider Business Mailing Address
First Line	:	2675 DORIS AVE
Second Line	:
City	:	NORTH BELLMORE
State	:	NY
Zip	:	11710-2070
Country	:	US
Telephone Number	:	516-241-4801
Fax Number	:	631-853-7389

Provider Business Practice Location Address
First Line	:	1173 BELLMORE RD
Second Line	:
City	:	NORTH BELLMORE
State	:	NY
Zip	:	11710-3757
Country	:	US
Telephone Number	:	516-241-4801
Fax Number	:	631-853-7389

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2010
Last Update Date	:	01/14/2010

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