Basic Information
| Provider Information | |||||||||
| NPI: | 1659558658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | BRAHM | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GORDON | ||||||||
| OtherFirstName: | XANDER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | SSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 460 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840110460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012983446 | ||||||||
| FaxNumber: | 8012983449 | ||||||||
| Practice Location | |||||||||
| Address1: | 934 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840414250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015461168 | ||||||||
| FaxNumber: | 8015440770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 5503536-3503 | UT | N | Behavioral Health & Social Service Providers | Social Worker | 390200000X | 5503536-3503 | UT | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.