Provider Demographics
NPI:1043424377
Name:VAN GORDEN, JEFFREY DAVID (OT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DAVID
Last Name:VAN GORDEN
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534
Mailing Address - Country:US
Mailing Address - Phone:518-828-7601
Mailing Address - Fax:
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534
Practice Address - Country:US
Practice Address - Phone:518-828-7601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
62511225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist