Healthcare Provider Details

I. General information

NPI: 1821613258
Provider Name (Legal Business Name): SARAH MICHELLE GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 W COLUMBIA AVE
KISSIMMEE FL
34741-3436
US

IV. Provider business mailing address

3642 MOCA DR
SAINT CLOUD FL
34772-8148
US

V. Phone/Fax

Practice location:
  • Phone: 407-201-6255
  • Fax:
Mailing address:
  • Phone: 407-928-1493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: