Active NPI
Eliza Lee Gordon, PHD
- Clinical Psychologist
- Chesterfield, MO
National Provider Identifier
1104384098
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 2022012232
- Practice address
- 15480 Elk Ridge LN
Chesterfield, MO 63017-5313 - Phone
- (801) 683-9068
- NPI assigned
- Mar 9, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Health Psychologist | 103TH0004X | 2022012232 | MO | |
| Clinical Psychologist | 103TC0700X | 2022012232 | MO | Primary |
Addresses
Primary practice location
15480 Elk Ridge LN
Chesterfield, MO 63017-5313
Mailing address
1734 Clarkson Rd # 1122
Chesterfield, MO 63017-4976
Phone (801) 683-9068
Other names 1
- Ellie Gordon
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jul 1, 2024 through Jul 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2022012232 | MO | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1552089600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1663718400000",
"number": "1104384098",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1734 CLARKSON RD # 1122",
"city": "CHESTERFIELD",
"state": "MO",
"postal_code": "630174976",
"telephone_number": "801-683-9068"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "15480 ELK RIDGE LN",
"city": "CHESTERFIELD",
"state": "MO",
"postal_code": "630175313",
"telephone_number": "801-683-9068"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GORDON",
"first_name": "ELIZA",
"middle_name": "LEE",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-03-09",
"last_updated": "2022-09-21",
"certification_date": "2022-09-21",
"status": "A"
},
"taxonomies": [
{
"code": "103TH0004X",
"taxonomy_group": "",
"desc": "Psychologist, Health",
"state": "MO",
"license": "2022012232",
"primary": false
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MO",
"license": "2022012232",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "ELLIE",
"last_name": "GORDON",
"credential": "PHD",
"code": "5",
"type": "Other Name"
}
]
}Other providers in Chesterfield, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.