Provider Demographics
NPI:1942440524
Name:GORDON, BETH AMELIA (OTR)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:AMELIA
Last Name:GORDON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:AMELIA
Other - Last Name:HOFSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-273-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103698225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist