Provider Demographics
NPI:1255736484
Name:GORDON, NATANA
Entity type:Individual
Prefix:
First Name:NATANA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12211-1432
Mailing Address - Country:US
Mailing Address - Phone:518-320-5663
Mailing Address - Fax:
Practice Address - Street 1:361 E 19TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2888
Practice Address - Country:US
Practice Address - Phone:212-721-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019189-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY208311672Medicaid