Provider Demographics
NPI:1063234102
Name:GORDON, CHEYENNE JANAY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:JANAY
Last Name:GORDON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23511 56TH AVE W UNIT 211
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-5279
Mailing Address - Country:US
Mailing Address - Phone:425-418-8373
Mailing Address - Fax:
Practice Address - Street 1:4407 116TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-8568
Practice Address - Country:US
Practice Address - Phone:425-418-8373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL61426839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist