Provider Demographics
NPI:1316630684
Name:GORDON, AMY (MED LABA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MED LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-3831
Mailing Address - Country:US
Mailing Address - Phone:508-975-1160
Mailing Address - Fax:
Practice Address - Street 1:29 S PARK AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-3831
Practice Address - Country:US
Practice Address - Phone:508-975-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2057103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst