Provider Demographics
NPI:1417318577
Name:GORDON, BRENT M (CADC I)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:M
Last Name:GORDON
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7140
Mailing Address - Country:US
Mailing Address - Phone:541-326-4905
Mailing Address - Fax:541-608-2888
Practice Address - Street 1:5505 S PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535
Practice Address - Country:US
Practice Address - Phone:541-326-4905
Practice Address - Fax:541-608-2888
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)