Provider Demographics
NPI:1154834604
Name:GORDON, NICOLE (OTRL)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 INTERFACE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9176
Mailing Address - Country:US
Mailing Address - Phone:734-627-8015
Mailing Address - Fax:
Practice Address - Street 1:5840 INTERFACE DR STE 400
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9176
Practice Address - Country:US
Practice Address - Phone:734-627-8001
Practice Address - Fax:734-433-1989
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009989225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist