Provider Demographics
NPI:1750051009
Name:GORDILLO, JUAN (RBT)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:GORDILLO
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-6025
Mailing Address - Country:US
Mailing Address - Phone:256-457-8668
Mailing Address - Fax:
Practice Address - Street 1:2916 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:FULTONDALE
Practice Address - State:AL
Practice Address - Zip Code:35068-6025
Practice Address - Country:US
Practice Address - Phone:256-457-8668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-21-183959106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician