Healthcare Provider Details

I. General information

NPI: 1518507979
Provider Name (Legal Business Name): TAYLOR NIKOLE GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 11/28/2024
Certification Date: 11/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NE HOOD AVE OFC B
GRESHAM OR
97030-7303
US

IV. Provider business mailing address

501 NE HOOD AVE OFC B
GRESHAM OR
97030-7303
US

V. Phone/Fax

Practice location:
  • Phone: 503-208-5288
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: