Provider Demographics
NPI:1104002526
Name:GORDON, ANGELINA
Entity Type:Individual
Prefix:MS
First Name:ANGELINA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2546 E 13TH ST
Mailing Address - Street 2:APT. A11
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4358
Mailing Address - Country:US
Mailing Address - Phone:718-207-4406
Mailing Address - Fax:
Practice Address - Street 1:2546 E 13TH ST
Practice Address - Street 2:APT A11
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-4306
Practice Address - Country:US
Practice Address - Phone:347-217-6983
Practice Address - Fax:347-205-7929
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist