Provider Demographics
NPI:1467341735
Name:GORDY, HEATHER GRACE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:GRACE
Last Name:GORDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 S KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4626
Mailing Address - Country:US
Mailing Address - Phone:646-255-3770
Mailing Address - Fax:
Practice Address - Street 1:3204 S KELLY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4626
Practice Address - Country:US
Practice Address - Phone:646-255-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR29120225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist