Provider Demographics
NPI:1003352055
Name:GORDON, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 ROBAK DR
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-1642
Mailing Address - Country:US
Mailing Address - Phone:617-331-3786
Mailing Address - Fax:
Practice Address - Street 1:1940 BONITA DR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-5524
Practice Address - Country:US
Practice Address - Phone:831-684-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-15
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT16180225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics