Provider Demographics
NPI:1942306675
Name:GORDON, CLIFFORD I (EDD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:I
Last Name:GORDON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 OLD CHIMNEY RD
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:RI
Mailing Address - Zip Code:02806-3243
Mailing Address - Country:US
Mailing Address - Phone:401-247-2798
Mailing Address - Fax:401-245-5762
Practice Address - Street 1:36 BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:PASCOAG
Practice Address - State:RI
Practice Address - Zip Code:02859-3131
Practice Address - Country:US
Practice Address - Phone:401-568-7661
Practice Address - Fax:401-245-5762
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00331103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI193805OtherHARVARD PILGRIM
RI7057168Medicaid
RI00-5303OtherBCHIP
RI0716OtherNEIGHBORHOOD
RI411814OtherMEDICARE GROUP
RI61-00445OtherUNITED HEALTH
RI304940OtherBCBS