MEDICARE: LATRICE GORDON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265995641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATRICE GORDON

Provider Business Mailing Address
First Line	:	3433 HERON ISLAND DR
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34655-3029
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3433 HERON ISLAND DR
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34655-3029
Country	:	US
Telephone Number	:	815-546-5613
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2019
Last Update Date	:	04/11/2019

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Directions to “ LATRICE GORDON ” Practice Location

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