Provider Demographics
NPI:1114438629
Name:GORDON, MERIDITH TILLEY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MERIDITH
Middle Name:TILLEY
Last Name:GORDON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 RANDY RD
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-6406
Mailing Address - Country:US
Mailing Address - Phone:972-824-7714
Mailing Address - Fax:
Practice Address - Street 1:300 E DAVIS ST
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-4610
Practice Address - Country:US
Practice Address - Phone:972-882-7834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT52862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT5286OtherTEXAS AT LICENSE