Provider Demographics
NPI:1205162674
Name:GORDON, JUSTIN E (DPT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:E
Last Name:GORDON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:502-882-9379
Mailing Address - Fax:502-587-5728
Practice Address - Street 1:3150 ROGERS RD STE 216
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7068
Practice Address - Country:US
Practice Address - Phone:919-229-8363
Practice Address - Fax:919-229-8356
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25049225100000X
NCP17533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist