Provider Demographics
NPI:1356475800
Name:GORDON, VONDA BAILEY
Entity type:Individual
Prefix:MS
First Name:VONDA
Middle Name:BAILEY
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 1:2565 JUDGE FRAN JAMIESON WAY
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-5998
Mailing Address - Country:US
Mailing Address - Phone:321-409-2136
Mailing Address - Fax:321-409-2140
Practice Address - Street 1:2565 JUDGE FRAN JAMIESON WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-5998
Practice Address - Country:US
Practice Address - Phone:321-409-2136
Practice Address - Fax:321-409-2140
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL760055100Medicaid