Provider Demographics
NPI:1518606185
Name:GORDON, SHAIKIREA MALASIA
Entity Type:Individual
Prefix:
First Name:SHAIKIREA
Middle Name:MALASIA
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LONG CREEK LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-8601
Mailing Address - Country:US
Mailing Address - Phone:904-638-6388
Mailing Address - Fax:904-485-8829
Practice Address - Street 1:10 LONG CREEK LN
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-8601
Practice Address - Country:US
Practice Address - Phone:904-206-8804
Practice Address - Fax:904-485-8829
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-207530106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician