Provider Demographics
NPI:1770756298
Name:MCCRAE, GORDON L (CCMA)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:L
Last Name:MCCRAE
Suffix:
Gender:M
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 BROADWAY
Mailing Address - Street 2:SUITE #1
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-3402
Mailing Address - Country:US
Mailing Address - Phone:973-357-1555
Mailing Address - Fax:973-357-2640
Practice Address - Street 1:714 BROADWAY
Practice Address - Street 2:SUITE #1
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-3402
Practice Address - Country:US
Practice Address - Phone:973-357-1555
Practice Address - Fax:973-357-2640
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ6622-5661171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6622-5661OtherNHA