Provider Demographics
NPI:1386089647
Name:MANNING, GORDON
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:
Last Name:MANNING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11445 CAMBRAY CREEK LOOP
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-3925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11445 CAMBRAY CREEK LOOP
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-3925
Practice Address - Country:US
Practice Address - Phone:813-727-0509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-19-9721106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst