Provider Demographics
NPI:1104985969
Name:GORDON, ALAN R (LCSW PHD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:R
Last Name:GORDON
Suffix:
Gender:M
Credentials:LCSW PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:797 BEAVER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-4731
Mailing Address - Country:US
Mailing Address - Phone:850-539-4053
Mailing Address - Fax:
Practice Address - Street 1:797 BEAVER CREEK LN
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-4731
Practice Address - Country:US
Practice Address - Phone:850-539-4053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 19671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical