Provider Demographics
NPI:1528512209
Name:GORDON, LEIFA ROSE (LMSW)
Entity type:Individual
Prefix:
First Name:LEIFA
Middle Name:ROSE
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BECKETT ST
Mailing Address - Street 2:APT 2
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4402
Mailing Address - Country:US
Mailing Address - Phone:207-491-4951
Mailing Address - Fax:
Practice Address - Street 1:75 BECKETT ST
Practice Address - Street 2:APT 2
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4402
Practice Address - Country:US
Practice Address - Phone:207-491-4951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC161561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical