Provider Demographics
NPI:1295867489
Name:GORDON, CAROL M (PT, PHD, OCS)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:M
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT, PHD, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 BERNICE DR
Mailing Address - Street 2:
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-3366
Mailing Address - Country:US
Mailing Address - Phone:630-350-2736
Mailing Address - Fax:630-350-2842
Practice Address - Street 1:143 BERNICE DR
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-3366
Practice Address - Country:US
Practice Address - Phone:630-350-2736
Practice Address - Fax:630-350-2842
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12792210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL79474Medicare ID - Type Unspecified