Provider Demographics
NPI:1851807622
Name:GORDON, ELIZABETH (MED, CALT, CDT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MED, CALT, CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 OLD ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2502
Mailing Address - Country:US
Mailing Address - Phone:703-855-8133
Mailing Address - Fax:
Practice Address - Street 1:196 OLD ORCHARD LN
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2502
Practice Address - Country:US
Practice Address - Phone:703-855-8133
Practice Address - Fax:703-855-8133
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5436174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist