Provider Demographics
NPI:1376683607
Name:GORDON, ANNE CAROL (PT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:CAROL
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16616 S 37TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7967
Mailing Address - Country:US
Mailing Address - Phone:480-759-1999
Mailing Address - Fax:
Practice Address - Street 1:1460 N PINAL AVE
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-3337
Practice Address - Country:US
Practice Address - Phone:520-876-3614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ590936OtherAHCCCS