Provider Demographics
NPI:1922562941
Name:GORDON, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15314 WILLVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77489-2403
Mailing Address - Country:US
Mailing Address - Phone:281-886-6108
Mailing Address - Fax:
Practice Address - Street 1:15314 WILLVIEW RD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77489-2403
Practice Address - Country:US
Practice Address - Phone:281-886-6108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities