Provider Demographics
NPI:1124709605
Name:GORDON, VIRGINIA ANN
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ANN
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 1:1455 VALLEY DR # 5504
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-0805
Mailing Address - Country:US
Mailing Address - Phone:801-500-6225
Mailing Address - Fax:
Practice Address - Street 1:1455 VALLEY DR # 5504
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-0805
Practice Address - Country:US
Practice Address - Phone:801-500-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician