Provider Demographics
NPI:1851882658
Name:GORDON, BRANDI (BCBA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18115 PINE W
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48193-8316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18115 PINE W
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN
Practice Address - State:MI
Practice Address - Zip Code:48193-8316
Practice Address - Country:US
Practice Address - Phone:313-627-5977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-18-47320106S00000X
MIBCBA-19-6495-184575103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician