Provider Demographics
NPI:1255980199
Name:GORDON, KAITLYN (BCABA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 MUSEUM RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4739
Mailing Address - Country:US
Mailing Address - Phone:501-358-6535
Mailing Address - Fax:
Practice Address - Street 1:1301 MUSEUM RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4739
Practice Address - Country:US
Practice Address - Phone:501-358-6535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
AR0-22-13843106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1255980199Medicaid