Individual
AYANNA HEAVENLY-MARIEA GORDON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
13765 VINTAGE DR SW, PORT ORCHARD, WA 98367-7391
(253) 970-2414
Mailing address
13765 VINTAGE DR SW, PORT ORCHARD, WA 98367-7391
(253) 970-2414
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
WDLGLJH400FB
WA
Other
Enumeration date
01/17/2024
Last updated
01/17/2024
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