Healthcare Provider Details

I. General information

NPI: 1780590133
Provider Name (Legal Business Name): KAYLA LABRE GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4897 BENNETTS PASTURE RD UNIT 5354
SUFFOLK VA
23435-1362
US

IV. Provider business mailing address

4245 INNSLAKE DR APT 1210
GLEN ALLEN VA
23060-5506
US

V. Phone/Fax

Practice location:
  • Phone: 757-774-8250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: