Provider Demographics
NPI:1235446261
Name:GORDON, MARY KATHLEEN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHLEEN
Last Name:GORDON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:KATHLEEN
Other - Last Name:SHOOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-0747
Mailing Address - Country:US
Mailing Address - Phone:309-852-7931
Mailing Address - Fax:
Practice Address - Street 1:1051 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-8354
Practice Address - Country:US
Practice Address - Phone:309-852-7931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009143225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist