Provider Demographics
NPI:1215169602
Name:GORDON, HOLLY LEE (LCSW)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:LEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:110 ALCOLADE DR E
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3839
Mailing Address - Country:US
Mailing Address - Phone:631-294-0216
Mailing Address - Fax:631-722-6221
Practice Address - Street 1:468 MAIN ST
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-3407
Practice Address - Country:US
Practice Address - Phone:631-294-0216
Practice Address - Fax:631-772-6221
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079684-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker