Provider Demographics
NPI:1720591498
Name:GORDON, DAVIAN JACOB
Entity Type:Individual
Prefix:
First Name:DAVIAN
Middle Name:JACOB
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 1:7010 TOWN FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89179-1505
Mailing Address - Country:US
Mailing Address - Phone:702-480-9057
Mailing Address - Fax:
Practice Address - Street 1:7010 TOWN FOREST AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89179-1505
Practice Address - Country:US
Practice Address - Phone:702-480-9057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1604652634103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1604652634Medicaid