Provider Demographics
NPI:1689139131
Name:GORDON, EMILY BONNIE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:BONNIE
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 1:6004 UNITAS LN NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4939
Mailing Address - Country:US
Mailing Address - Phone:505-514-7452
Mailing Address - Fax:
Practice Address - Street 1:6004 UNITAS LN NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4939
Practice Address - Country:US
Practice Address - Phone:505-514-7452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMYIF905037320Medicaid