Provider Demographics
NPI:1871818369
Name:GORDON, BRIAN HEATH (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:HEATH
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2427
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-2427
Mailing Address - Country:US
Mailing Address - Phone:601-869-5898
Mailing Address - Fax:601-589-0825
Practice Address - Street 1:357 TOWNE CENTER BLVD STE 403
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4844
Practice Address - Country:US
Practice Address - Phone:601-869-5898
Practice Address - Fax:601-589-0825
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS48839103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist