Provider Demographics
NPI:1114130853
Name:GORDON, BRENDA LEE (MS CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10088 DEER WOOD DR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-8359
Mailing Address - Country:US
Mailing Address - Phone:417-624-4325
Mailing Address - Fax:
Practice Address - Street 1:1901A BUENA VISTA AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-3178
Practice Address - Country:US
Practice Address - Phone:417-358-3440
Practice Address - Fax:417-359-5617
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO01639235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist