Provider Demographics
NPI:1124611900
Name:GORDUYN, JULIANNA MARIE
Entity type:Individual
Prefix:
First Name:JULIANNA
Middle Name:MARIE
Last Name:GORDUYN
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 1:1200 W ROBERT AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-5935
Mailing Address - Country:US
Mailing Address - Phone:505-249-4286
Mailing Address - Fax:
Practice Address - Street 1:732 N NORMA ST UNIT B
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3507
Practice Address - Country:US
Practice Address - Phone:760-454-7281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician