Provider Demographics
NPI:1508627555
Name:GORDON, AYANNA HEAVENLY-MARIEA
Entity Type:Individual
Prefix:
First Name:AYANNA
Middle Name:HEAVENLY-MARIEA
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 1:13765 VINTAGE DR SW
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-7391
Mailing Address - Country:US
Mailing Address - Phone:253-970-2414
Mailing Address - Fax:
Practice Address - Street 1:13765 VINTAGE DR SW
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-7391
Practice Address - Country:US
Practice Address - Phone:253-970-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWDLGLJH400FB106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician