Provider Demographics
NPI:1174992762
Name:GORDON, ISIASHA MARK (SLP)
Entity type:Individual
Prefix:
First Name:ISIASHA
Middle Name:MARK
Last Name:GORDON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:ISIASHA
Other - Middle Name:
Other - Last Name:MARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:181 TOWN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-5841
Mailing Address - Country:US
Mailing Address - Phone:803-642-0700
Mailing Address - Fax:803-642-0588
Practice Address - Street 1:181 TOWN CREEK RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-5841
Practice Address - Country:US
Practice Address - Phone:803-642-0700
Practice Address - Fax:803-642-0588
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5862235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5862OtherSTATE LICENSE