Provider Demographics
NPI:1104392042
Name:GORDON, TYLER J (CMHC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:GORDON
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 RIDGEVIEW DR STE 104
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2696
Mailing Address - Country:US
Mailing Address - Phone:801-822-2407
Mailing Address - Fax:
Practice Address - Street 1:750 RIDGEVIEW DR STE 104
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2696
Practice Address - Country:US
Practice Address - Phone:801-822-2407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10977493-6009101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT82-1067031OtherSOLE PROPRIETOR BUSINESS