Provider Demographics
NPI:1396755617
Name:GORDON, DAVID WAYNE (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
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 1:1611 COLLEY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1677
Mailing Address - Country:US
Mailing Address - Phone:757-288-9741
Mailing Address - Fax:757-622-3944
Practice Address - Street 1:1611 COLLEY AVE STE D
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1677
Practice Address - Country:US
Practice Address - Phone:757-288-9741
Practice Address - Fax:757-625-2563
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000716103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00707452Medicaid