Provider Demographics
NPI:1275392987
Name:GORDON, TALIA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 RUFFIN RD STE J
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1830
Mailing Address - Country:US
Mailing Address - Phone:858-279-5570
Mailing Address - Fax:
Practice Address - Street 1:3959 RUFFIN RD STE J
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1830
Practice Address - Country:US
Practice Address - Phone:858-279-5570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA302588OtherSTATE LICENSE