Provider Demographics
NPI:1497823496
Name:GORDON, PAMELA (PT)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:M
Other - Last Name:TOOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3536 MERIDIAN CROSSINGS
Mailing Address - Street 2:STE 240
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4584
Mailing Address - Country:US
Mailing Address - Phone:517-347-2495
Mailing Address - Fax:517-347-3540
Practice Address - Street 1:3536 MERIDIAN CROSSINGS
Practice Address - Street 2:STE 240
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4584
Practice Address - Country:US
Practice Address - Phone:517-347-2495
Practice Address - Fax:517-347-3540
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C31919OtherBCBSM BCN
MI650C31919OtherBCBSM BCN