Provider Demographics
NPI:1316749146
Name:GORDON, ASHLEY NICOLE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:GORDON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 PARK OVERLOOK DR UNIT 301
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-7406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6396 THORNBERRY CT STE 710
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-7815
Practice Address - Country:US
Practice Address - Phone:859-282-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBACB1262086106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician