Provider Demographics
NPI:1255408993
Name:GORDON, DOROTHY MIA (OTRL)
Entity type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:MIA
Last Name:GORDON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 S INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-3075
Mailing Address - Country:US
Mailing Address - Phone:706-624-3000
Mailing Address - Fax:706-624-3001
Practice Address - Street 1:1114 S WALL ST
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-3062
Practice Address - Country:US
Practice Address - Phone:706-624-3000
Practice Address - Fax:706-624-3001
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001642225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00751308FMedicaid