Provider Demographics
NPI:1669420212
Name:GORDON, MEGAN TUCKER (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:TUCKER
Last Name:GORDON
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 1:8 ZACHARY PL
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3273
Mailing Address - Country:US
Mailing Address - Phone:706-951-5573
Mailing Address - Fax:
Practice Address - Street 1:8 ZACHARY PL
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3273
Practice Address - Country:US
Practice Address - Phone:706-951-5573
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2958225X00000X
GAOT004032225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1602Medicaid