Provider Demographics
NPI:1659927275
Name:GORDON, LATASHA M
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:M
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 1:11914 S ROUTE 59 UNIT 124
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5110
Mailing Address - Country:US
Mailing Address - Phone:815-729-2160
Mailing Address - Fax:815-220-5619
Practice Address - Street 1:11914 S ROUTE 59 UNIT 124
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5110
Practice Address - Country:US
Practice Address - Phone:815-729-2160
Practice Address - Fax:815-220-5619
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician