Provider Demographics
NPI:1033939483
Name:GORDON, MATTHEW LUCAS
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LUCAS
Last Name:GORDON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 YORK ROAD
Mailing Address - Street 2:STUDENT LIFE- SETON 08B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212
Mailing Address - Country:US
Mailing Address - Phone:470-833-8900
Mailing Address - Fax:
Practice Address - Street 1:711 W 40TH ST STE 206
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2108
Practice Address - Country:US
Practice Address - Phone:410-842-6055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA01046390200000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program