MEDICARE: DR. JUDITH R GORDON PH.D.

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	103T00000X	Psychologist	PY00000682	WA

General Provider Information

NPI Number	:	1609987536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUDITH R GORDON PH.D.

Provider Business Mailing Address
First Line	:	101 NW 58TH ST
Second Line	:	#19
City	:	SEATTLE
State	:	WA
Zip	:	98107-2074
Country	:	US
Telephone Number	:	206-324-6450
Fax Number	:	206-324-2176

Provider Business Practice Location Address
First Line	:	753 N 35TH ST
Second Line	:	SUITE 305
City	:	SEATTLE
State	:	WA
Zip	:	98103-8870
Country	:	US
Telephone Number	:	206-324-6450
Fax Number	:	206-324-2176

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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