Provider Demographics
NPI:1629363890
Name:GORDON, AMBER L (LMP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:L
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 ORCA DR NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-1943
Mailing Address - Country:US
Mailing Address - Phone:253-431-9636
Mailing Address - Fax:
Practice Address - Street 1:1033 N TACOMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-2928
Practice Address - Country:US
Practice Address - Phone:253-474-9670
Practice Address - Fax:253-474-9692
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024516225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist