Provider Demographics
NPI:1811238553
Name:MICHAELS, GORDON L
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:L
Last Name:MICHAELS
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 1:2409 JENKS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4308
Mailing Address - Country:US
Mailing Address - Phone:850-913-9994
Mailing Address - Fax:850-913-9936
Practice Address - Street 1:2409 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4308
Practice Address - Country:US
Practice Address - Phone:850-913-9994
Practice Address - Fax:850-913-9936
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4830237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist