Provider Demographics
NPI:1750020640
Name:ECKER-GORDON, DALE L (BS BT)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:L
Last Name:ECKER-GORDON
Suffix:
Gender:F
Credentials:BS BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 W 190TH ST STE 2200
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4344
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:
Practice Address - Street 1:1650 SPRUCE ST STE 102
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7403
Practice Address - Country:US
Practice Address - Phone:951-357-6926
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106SOOOOOX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician