Provider Demographics
NPI:1104586676
Name:GORDON, MONIQUE STEPHANIE
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:STEPHANIE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-4019
Mailing Address - Country:US
Mailing Address - Phone:203-729-0341
Mailing Address - Fax:
Practice Address - Street 1:16 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-4019
Practice Address - Country:US
Practice Address - Phone:203-729-0341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-26
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002744101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health