Provider Demographics
NPI:1194186692
Name:GORDON, YOLANDA MCCLOUD (COTA/L)
Entity Type:Individual
Prefix:
First Name:YOLANDA
Middle Name:MCCLOUD
Last Name:GORDON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 WELLMORE DR
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29708-0124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 WELLMORE DR
Practice Address - Street 2:
Practice Address - City:TEGA CAY
Practice Address - State:SC
Practice Address - Zip Code:29708-0124
Practice Address - Country:US
Practice Address - Phone:803-835-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3559224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant