Provider Demographics
NPI:1063009793
Name:AVILES-GORDON, CHARDA
Entity Type:Individual
Prefix:
First Name:CHARDA
Middle Name:
Last Name:AVILES-GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5526 N ACADEMY BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3688
Mailing Address - Country:US
Mailing Address - Phone:719-301-5100
Mailing Address - Fax:
Practice Address - Street 1:5526 N ACADEMY BLVD STE 109
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3688
Practice Address - Country:US
Practice Address - Phone:719-301-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-20-149700106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician