Provider Demographics
NPI:1447364955
Name:GORDON, DANIEL GRISWOLD (LMFT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:GRISWOLD
Last Name:GORDON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 DEERWOOD LN # U3
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-6114
Mailing Address - Country:US
Mailing Address - Phone:203-754-2079
Mailing Address - Fax:203-757-8914
Practice Address - Street 1:60 WATERBURY RD
Practice Address - Street 2:HERITAGE PROFESSIONAL SUITE 2A
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1250
Practice Address - Country:US
Practice Address - Phone:203-560-1158
Practice Address - Fax:203-757-8914
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001060106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist