Provider Demographics
NPI:1033654462
Name:GORDILLO, ANDRES (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:GORDILLO
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 E STATE ROAD 64
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-9041
Mailing Address - Country:US
Mailing Address - Phone:561-305-7975
Mailing Address - Fax:
Practice Address - Street 1:3823 E STATE ROAD 64 FL 34208
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9041
Practice Address - Country:US
Practice Address - Phone:941-745-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15492235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019549700Medicaid