Provider Demographics
NPI:1386762185
Name:GORDON, ALISA JOY (LPN)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:JOY
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8907 RUTLAND ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-2072
Mailing Address - Country:US
Mailing Address - Phone:313-933-4284
Mailing Address - Fax:313-852-1631
Practice Address - Street 1:13220 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3610
Practice Address - Country:US
Practice Address - Phone:313-868-1946
Practice Address - Fax:313-852-1631
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703056485164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1740313238OtherCHRISTIAN GUIDANCE CENTER
MI3022440Medicaid