Provider Demographics
NPI:1003952474
Name:GORDON, PAMELA (OT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 34TH AVE APT 5C BLDG 14
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4304
Mailing Address - Country:US
Mailing Address - Phone:718-932-3373
Mailing Address - Fax:
Practice Address - Street 1:189 WHEATLEY RD
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-2641
Practice Address - Country:US
Practice Address - Phone:516-626-1075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003342224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant