Provider Demographics
NPI:1821376070
Name:GORDON, KELLY A (CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:GORDON
Suffix:
Gender:F
Credentials: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:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:NY
Mailing Address - Zip Code:12917-0069
Mailing Address - Country:US
Mailing Address - Phone:518-483-6231
Mailing Address - Fax:
Practice Address - Street 1:42 HUSKIE LN
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-2451
Practice Address - Country:US
Practice Address - Phone:518-483-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0105881235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist