Provider Demographics
NPI:1801010079
Name:GORDON, JOHANNA EVERETT (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:EVERETT
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 MARIAN WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5872
Mailing Address - Country:US
Mailing Address - Phone:301-502-0961
Mailing Address - Fax:
Practice Address - Street 1:700 TOLL HOUSE AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4575
Practice Address - Country:US
Practice Address - Phone:301-815-8878
Practice Address - Fax:301-668-2352
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02575235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist