Basic Information
| Provider Information | |||||||||
| NPI: | 1295171775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 W SUMNER AVE | ||||||||
| Address2: | |||||||||
| City: | ROSELLE PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 072041225 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 67 WALNUT AVE STE 207 | ||||||||
| Address2: | |||||||||
| City: | CLARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070661640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329822888 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2013 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 37PC00710200 | NJ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.