Provider Demographics
NPI:1285490425
Name:GORDON, DAIJJAH T
Entity type:Individual
Prefix:
First Name:DAIJJAH
Middle Name:T
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 1:3610 MYSTIC VALLEY PARKWAY
Mailing Address - Street 2:N1009
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:857-346-9279
Mailing Address - Fax:
Practice Address - Street 1:3610 MYSTIC VALLEY PARKWAY
Practice Address - Street 2:N1009
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-0215
Practice Address - Country:US
Practice Address - Phone:857-346-9279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician