Provider Demographics
NPI:1558759381
Name:GORDON, ASHLEY
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:
Last Name:GORDON
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 1:1726 SERPENTINE DR S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-6057
Mailing Address - Country:US
Mailing Address - Phone:207-208-9395
Mailing Address - Fax:
Practice Address - Street 1:9393 PARK BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33777-4140
Practice Address - Country:US
Practice Address - Phone:727-391-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-01
Last Update Date:2015-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16675225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist