Healthcare Provider Details

I. General information

NPI: 1104755099
Provider Name (Legal Business Name): MARC A GORDON SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 CARTER AVE SE
ATLANTA GA
30317-3244
US

IV. Provider business mailing address

440 CARTER AVE SE
ATLANTA GA
30317-3244
US

V. Phone/Fax

Practice location:
  • Phone: 323-244-8545
  • Fax:
Mailing address:
  • Phone: 323-244-8545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: