Provider Demographics
NPI:1811331796
Name:GORDON, RAVEN S (COTA/L)
Entity type:Individual
Prefix:MS
First Name:RAVEN
Middle Name:S
Last Name:GORDON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 ARTHUR ST
Mailing Address - Street 2:#107
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46404-3563
Mailing Address - Country:US
Mailing Address - Phone:219-902-1498
Mailing Address - Fax:
Practice Address - Street 1:2425 ARTHUR ST
Practice Address - Street 2:#107
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46404-3563
Practice Address - Country:US
Practice Address - Phone:219-902-1498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003528224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant