Provider Demographics
NPI:1720417686
Name:GORDON, LARA JO (COTA/L)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:JO
Last Name:GORDON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 SUMMER ST APT A
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246-3139
Mailing Address - Country:US
Mailing Address - Phone:207-942-3977
Mailing Address - Fax:
Practice Address - Street 1:175 BLUEBERRY LN
Practice Address - Street 2:LACONIA REHABILITATION CENTER
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246
Practice Address - Country:US
Practice Address - Phone:603-524-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0664224Z00000X
IDOTA-1267224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant