Provider Demographics
NPI:1508081019
Name:GORDONSMITH, BENITA (COTA)
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:GORDONSMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 MAID MARIAN CIR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4515
Mailing Address - Country:US
Mailing Address - Phone:254-634-1802
Mailing Address - Fax:
Practice Address - Street 1:4103 MAID MARIAN CIR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4515
Practice Address - Country:US
Practice Address - Phone:254-634-1802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208497224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant