Provider Demographics
NPI:1639691389
Name:GORDON, GABRIEL (LMT)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6303 SE HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3447
Mailing Address - Country:US
Mailing Address - Phone:971-570-2228
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST STE 302
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1056
Practice Address - Country:US
Practice Address - Phone:971-328-1689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023149225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist