Provider Demographics
NPI:1407661564
Name:GORDON, CHIDAE SEVILLE
Entity type:Individual
Prefix:
First Name:CHIDAE
Middle Name:SEVILLE
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 1:6656 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4641
Mailing Address - Country:US
Mailing Address - Phone:469-358-4740
Mailing Address - Fax:
Practice Address - Street 1:6656 DECATUR ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-4641
Practice Address - Country:US
Practice Address - Phone:469-358-4740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities