Provider Demographics
NPI:1770531857
Name:GORDON, ANN E (MA, CCC/SLP)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:E
Last Name:GORDON
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MILLS LN
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3805
Mailing Address - Country:US
Mailing Address - Phone:631-751-3838
Mailing Address - Fax:631-751-3767
Practice Address - Street 1:207 HALLOCK RD
Practice Address - Street 2:SUITE 6
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3033
Practice Address - Country:US
Practice Address - Phone:631-751-3838
Practice Address - Fax:631-751-3767
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000469-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist