Provider Demographics
NPI:1144989690
Name:GORDON, ANDRE LESLIE (MSE)
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:LESLIE
Last Name:GORDON
Suffix:
Gender:M
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 PITKIN AVE # 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-3824
Mailing Address - Country:US
Mailing Address - Phone:347-641-0343
Mailing Address - Fax:
Practice Address - Street 1:1516 BERGEN ST APT 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1783
Practice Address - Country:US
Practice Address - Phone:347-915-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency