Provider Demographics
NPI:1164788451
Name:GORDON, TRISH LUANN
Entity Type:Individual
Prefix:
First Name:TRISH
Middle Name:LUANN
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 1:3415 CUSTER ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3415 CUSTER ST
Practice Address - Street 2:SUITE C
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4356
Practice Address - Country:US
Practice Address - Phone:920-652-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator