Provider Demographics
NPI:1629376835
Name:GORDON, STEPHANIE VICKY (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:VICKY
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2874 SHELBY ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-4579
Mailing Address - Country:US
Mailing Address - Phone:901-451-0663
Mailing Address - Fax:901-466-1121
Practice Address - Street 1:2874 SHELBY ST
Practice Address - Street 2:SUITE 108
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4579
Practice Address - Country:US
Practice Address - Phone:901-451-0663
Practice Address - Fax:901-466-1121
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8591225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist