Provider Demographics
NPI:1427581636
Name:GORDON, TENNILLE
Entity Type:Individual
Prefix:
First Name:TENNILLE
Middle Name:
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 1:805 S KIRKMAN RD
Mailing Address - Street 2:205
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-2200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 S KIRKMAN RD
Practice Address - Street 2:205
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-2200
Practice Address - Country:US
Practice Address - Phone:407-245-0012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14647251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health