Provider Demographics
NPI:1700146552
Name:GORDON, ATHENA BOOLUKOS (EDM, PSYD)
Entity type:Individual
Prefix:DR
First Name:ATHENA
Middle Name:BOOLUKOS
Last Name:GORDON
Suffix:
Gender:F
Credentials:EDM, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 BAYSHORE BLVD
Mailing Address - Street 2:UNIT 1603
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-1669
Mailing Address - Country:US
Mailing Address - Phone:617-784-0771
Mailing Address - Fax:
Practice Address - Street 1:4201 BAYSHORE BLVD
Practice Address - Street 2:UNIT 1603
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-1669
Practice Address - Country:US
Practice Address - Phone:617-784-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8510103T00000X, 103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging