Provider Demographics
NPI:1265908875
Name:GORDON, TRISTYN TAILOR
Entity type:Individual
Prefix:MS
First Name:TRISTYN
Middle Name:TAILOR
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 STRAUB RD W APT 72
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1891
Mailing Address - Country:US
Mailing Address - Phone:567-560-7313
Mailing Address - Fax:
Practice Address - Street 1:1033 LARCHWOOD RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2424
Practice Address - Country:US
Practice Address - Phone:419-747-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician