Provider Demographics
NPI:1871215244
Name:GORDON, STACEY MICHELLE (LMFT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:CT
Mailing Address - Zip Code:06482-1333
Mailing Address - Country:US
Mailing Address - Phone:203-994-7858
Mailing Address - Fax:
Practice Address - Street 1:2960 POST RD STE 3B2
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1268
Practice Address - Country:US
Practice Address - Phone:203-307-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2949106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist