Provider Demographics
NPI:1972938207
Name:GORDON, MAKENZI (COTA)
Entity Type:Individual
Prefix:
First Name:MAKENZI
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8828 ORIOLE LN
Mailing Address - Street 2:
Mailing Address - City:WIND LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53185-5515
Mailing Address - Country:US
Mailing Address - Phone:920-645-5886
Mailing Address - Fax:
Practice Address - Street 1:8828 ORIOLE LN
Practice Address - Street 2:
Practice Address - City:WIND LAKE
Practice Address - State:WI
Practice Address - Zip Code:53185-5515
Practice Address - Country:US
Practice Address - Phone:920-645-5886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI502427224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant