Provider Demographics
NPI:1477787463
Name:GORDON, CHARLENE BRENDA (MA)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:BRENDA
Last Name:GORDON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16001 WEST NINE MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-849-3392
Mailing Address - Fax:248-849-2797
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3392
Practice Address - Fax:248-849-2797
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000454231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist