Provider Demographics
NPI:1134777212
Name:GORE-TISDALE, LADONNA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:LADONNA
Middle Name:
Last Name:GORE-TISDALE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6966 TOSCANA TRCE
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358-9563
Mailing Address - Country:US
Mailing Address - Phone:336-508-4924
Mailing Address - Fax:
Practice Address - Street 1:6966 TOSCANA TRCE
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:NC
Practice Address - Zip Code:27358-9563
Practice Address - Country:US
Practice Address - Phone:336-508-4924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2969225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics