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NPI Code Detail

MEDICARE: RAEGAN MACKENZIE GORDON

MEDICARE: RAEGAN MACKENZIE 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
1106S00000XBehavior TechnicianBACB901431TX

General Provider Information

NPI Number : 1346176260
Entity Type Code : Individual
Provider Name (Legal Business Name) : RAEGAN MACKENZIE GORDON
Provider Business Mailing Address
First Line : 4917 GOLDEN TRIANGLE BLVD STE 411
Second Line :
City : FORT WORTH
State : TX
Zip : 76244-4672
Country : US
Telephone Number : 817-754-4940
Fax Number : 817-717-8584
Provider Business Practice Location Address
First Line : 4917 GOLDEN TRIANGLE BLVD STE 411
Second Line :
City : FORT WORTH
State : TX
Zip : 76244-4672
Country : US
Telephone Number : 817-754-4940
Fax Number : 817-717-8584
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/18/2026
Last Update Date : 06/18/2026

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Directions to “ RAEGAN MACKENZIE GORDON ” Practice Location

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