Provider Demographics
NPI:1508494642
Name:GORDON, CARISSA NICHOLE (RBT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:NICHOLE
Last Name:GORDON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 SALERNO CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-4004
Mailing Address - Country:US
Mailing Address - Phone:407-738-2802
Mailing Address - Fax:
Practice Address - Street 1:3831 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4659
Practice Address - Country:US
Practice Address - Phone:407-559-4854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician