Provider Demographics
NPI:1235665977
Name:GORDON, TAMIKA (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-3006
Mailing Address - Country:US
Mailing Address - Phone:203-737-0779
Mailing Address - Fax:
Practice Address - Street 1:33 BERNHARD RD
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3900
Practice Address - Country:US
Practice Address - Phone:203-779-6466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0520031744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management