Provider Demographics
NPI:1780093898
Name:GORDON, MAISIE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MAISIE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13101 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-3803
Mailing Address - Country:US
Mailing Address - Phone:813-974-0602
Mailing Address - Fax:813-558-1343
Practice Address - Street 1:27650 CASHFORD CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6957
Practice Address - Country:US
Practice Address - Phone:813-963-6923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FLSZ10515235Z00000X
SA21105235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker