Provider Demographics
NPI:1174247308
Name:GORDON, MARY ELIZABETH (SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:GORDON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11623 ARBOR ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2991
Mailing Address - Country:US
Mailing Address - Phone:402-334-6063
Mailing Address - Fax:023-346-0634
Practice Address - Street 1:11623 ARBOR ST STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2991
Practice Address - Country:US
Practice Address - Phone:402-334-6063
Practice Address - Fax:402-334-6063
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE794235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist