Provider Demographics
NPI:1730563800
Name:GORDON, CAITLIN
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 FARMHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 FARMHOUSE DR
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-2171
Practice Address - Country:US
Practice Address - Phone:631-566-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst