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General NPI Number Information
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NPI Number | 1114130853
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Entity Type | Individual
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Provider Name | BRENDA LEE GORDON MS CCCSLP
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Gender | Female
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 10/18/2007
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Provider Practice Location Address
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Address Line | 1901A BUENA VISTA AVE
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City | CARTHAGE
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State | MO
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Zip | 64836-3178
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Country | US
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Telephone | 417-358-3440
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Fax | 417-359-5617
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Provider Business Mailing Address
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Address Line | 10088 DEER WOOD DR
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City | JOPLIN
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State | MO
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Zip | 64804-8359
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Country | US
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Telephone | 417-624-4325
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | MO01639
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License Number State | MO
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