Provider Demographics
NPI:1710747001
Name:GORDON, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E 7TH ST APT 205
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8049
Mailing Address - Country:US
Mailing Address - Phone:919-939-6303
Mailing Address - Fax:
Practice Address - Street 1:230 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MN
Practice Address - Zip Code:56307-9489
Practice Address - Country:US
Practice Address - Phone:320-845-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist