Provider Demographics
NPI:1689146672
Name:TSUBIRA, GORDON BERNERD (OTR/L)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:BERNERD
Last Name:TSUBIRA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LOHRVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51453-1031
Mailing Address - Country:US
Mailing Address - Phone:712-297-4722
Mailing Address - Fax:
Practice Address - Street 1:208 2ND ST
Practice Address - Street 2:
Practice Address - City:LOHRVILLE
Practice Address - State:IA
Practice Address - Zip Code:51453-1031
Practice Address - Country:US
Practice Address - Phone:712-297-4722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA076103225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty