Provider Demographics
NPI:1659558658
Name:GORDON, BRAHM ALEXANDER (SSW)
Entity Type:Individual
Prefix:
First Name:BRAHM
Middle Name:ALEXANDER
Last Name:GORDON
Suffix:
Gender:M
Credentials:SSW
Other - Prefix:
Other - First Name:XANDER
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SSW
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0460
Mailing Address - Country:US
Mailing Address - Phone:801-298-3446
Mailing Address - Fax:801-298-3449
Practice Address - Street 1:934 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4250
Practice Address - Country:US
Practice Address - Phone:801-546-1168
Practice Address - Fax:801-544-0770
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5503536-3503104100000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker