Provider Demographics
NPI:1093901225
Name:GORDON, SUSAN LEIGH (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGH
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-6026
Mailing Address - Country:US
Mailing Address - Phone:215-355-0623
Mailing Address - Fax:
Practice Address - Street 1:530 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6026
Practice Address - Country:US
Practice Address - Phone:215-355-0623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT005518L2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019326700002OtherMA