Provider Demographics
NPI:1700414265
Name:GORDON, GINA PATRICIA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:PATRICIA
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 1:1117 RIVERSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-2090
Mailing Address - Country:US
Mailing Address - Phone:248-767-0873
Mailing Address - Fax:
Practice Address - Street 1:1117 RIVERSTONE CIR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-2090
Practice Address - Country:US
Practice Address - Phone:248-767-0873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006870225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201006870OtherOT LICENSE