Provider Demographics
NPI:1821729815
Name:GORDON, KENDALL ELSBETH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:ELSBETH
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W LOUISE AVE APT 190
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-1258
Mailing Address - Country:US
Mailing Address - Phone:404-606-0316
Mailing Address - Fax:
Practice Address - Street 1:1515 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2424
Practice Address - Country:US
Practice Address - Phone:404-606-0316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12868159-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist