Provider Demographics
NPI:1285721753
Name:GORDON, DENNETT HOWE (PHD)
Entity type:Individual
Prefix:
First Name:DENNETT
Middle Name:HOWE
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5072
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-5072
Mailing Address - Country:US
Mailing Address - Phone:706-235-1400
Mailing Address - Fax:706-378-8840
Practice Address - Street 1:111 GREEN VIEW RD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4305
Practice Address - Country:US
Practice Address - Phone:706-235-1400
Practice Address - Fax:706-510-1357
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003017103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA108296834BMedicaid
GA68BBGSKMedicare PIN