Provider Demographics
NPI:1962764720
Name:REGAN - GORDON, THERESA MARIE (MSED)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MARIE
Last Name:REGAN - GORDON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 6TH ST
Mailing Address - Street 2:APT.2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3757
Mailing Address - Country:US
Mailing Address - Phone:718-499-4993
Mailing Address - Fax:
Practice Address - Street 1:573 6TH ST
Practice Address - Street 2:APT.2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3757
Practice Address - Country:US
Practice Address - Phone:718-499-4993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist