Provider Demographics
NPI:1982851895
Name:GORDON, CRYSTAL D (COTA/L)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:GORDON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 211B
Mailing Address - Street 2:
Mailing Address - City:BEECHER CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62414-9208
Mailing Address - Country:US
Mailing Address - Phone:217-783-2335
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 211B
Practice Address - Street 2:
Practice Address - City:BEECHER CITY
Practice Address - State:IL
Practice Address - Zip Code:62414-9208
Practice Address - Country:US
Practice Address - Phone:217-783-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002673224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant