Basic Information
| Provider Information | |||||||||
| NPI: | 1902292766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | SHAKINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | BA,AS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR-ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 72 WEST ST | ||||||||
| Address2: | DANBURY CLINICAL SERVICES | ||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068106531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037979778 | ||||||||
| FaxNumber: | 2037979858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 04/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.