Provider Demographics
NPI:1538702774
Name:GORDON, SHELBY MAE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:MAE
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:910 N WASHINGTON ST STE 201
Practice Address - Street 2:SUITE 202
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2260
Practice Address - Country:US
Practice Address - Phone:509-568-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT6206225100000X
WAPT60975819225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA113Medicaid