Provider Demographics
NPI:1730690835
Name:GORDON, DERRICK M (PHD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:M
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 OLD QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-1006
Mailing Address - Country:US
Mailing Address - Phone:203-675-4228
Mailing Address - Fax:
Practice Address - Street 1:389 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-2301
Practice Address - Country:US
Practice Address - Phone:203-789-7645
Practice Address - Fax:203-562-6355
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003297103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical