Provider Demographics
NPI:1407182405
Name:GORDY, M THOMAS III (CSI, LMT)
Entity Type:Individual
Prefix:MR
First Name:M THOMAS
Middle Name:
Last Name:GORDY
Suffix:III
Gender:M
Credentials:CSI, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 FOSTER DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-1208
Mailing Address - Country:US
Mailing Address - Phone:775-220-2482
Mailing Address - Fax:
Practice Address - Street 1:6135 LAKESIDE DR
Practice Address - Street 2:SUITE 119
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-8504
Practice Address - Country:US
Practice Address - Phone:775-220-2482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist