Provider Demographics
NPI:1770865420
Name:GORDON, QIANA L (LMT)
Entity Type:Individual
Prefix:MS
First Name:QIANA
Middle Name:L
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4457 COVINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-1214
Mailing Address - Country:US
Mailing Address - Phone:678-886-2203
Mailing Address - Fax:
Practice Address - Street 1:4376 NORTHWIND DR
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2474
Practice Address - Country:US
Practice Address - Phone:678-886-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007007225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist