Basic Information
| Provider Information | |||||||||
| NPI: | 1417318577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 E MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264905 | ||||||||
| FaxNumber: | 5416082888 | ||||||||
| Practice Location | |||||||||
| Address1: | 5505 S PACIFIC HWY | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264905 | ||||||||
| FaxNumber: | 5416082888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.