Provider Demographics
NPI:1245793660
Name:GORDON, AYANA MARIE
Entity Type:Individual
Prefix:
First Name:AYANA
Middle Name:MARIE
Last Name: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:PO BOX 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:1550 HOTEL CIR N STE 270
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2908
Practice Address - Country:US
Practice Address - Phone:619-814-6494
Practice Address - Fax:619-573-9850
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician