Provider Demographics
NPI:1396132320
Name:GORDON, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
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 1:2109 RUTHERFORD GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-3878
Mailing Address - Country:US
Mailing Address - Phone:404-861-0807
Mailing Address - Fax:
Practice Address - Street 1:3983 LAVISTA RD
Practice Address - Street 2:SUITE 164
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5153
Practice Address - Country:US
Practice Address - Phone:404-861-0807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0596846951744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management