Healthcare Provider Details

I. General information

NPI: 1851882658
Provider Name (Legal Business Name): BRANDI GORDON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13304 COMMONWEALTH ST
SOUTHGATE MI
48195-1285
US

IV. Provider business mailing address

13304 COMMONWEALTH ST
SOUTHGATE MI
48195-1285
US

V. Phone/Fax

Practice location:
  • Phone: 313-627-5977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBCBA-19-6495-184575
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-47320
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: