1841413713 NPI number — LYNN MARIE GORDON PH.D.

Table of content: LYNN MARIE GORDON PH.D. (NPI 1841413713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841413713 NPI number — LYNN MARIE GORDON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
LYNN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841413713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 519
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTE RIO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95462-0519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-865-1200
Provider Business Mailing Address Fax Number:
707-865-3151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19375 HIGHWAY 116
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTE RIO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-865-1200
Provider Business Practice Location Address Fax Number:
707-865-3151
Provider Enumeration Date:
04/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  PSB 32692 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: PSY 26528 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PSB 32692 . This is a "PSYCHOLOGICAL ASSISTANT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PSY 26528 . This is a "LICENSED PSYCHOLOGIST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".