Provider Demographics
NPI:1679093884
Name:CHINAMASA, GORDON
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:CHINAMASA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 BRICK KILN RD UNIT 5105
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-3264
Mailing Address - Country:US
Mailing Address - Phone:682-365-3785
Mailing Address - Fax:
Practice Address - Street 1:391 VARNUM AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2119
Practice Address - Country:US
Practice Address - Phone:978-455-3397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222718104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker