Provider Demographics
NPI:1366126831
Name:GORDON, LIANA LYNN (OTR, MOT)
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:LYNN
Last Name:GORDON
Suffix:
Gender:F
Credentials:OTR, MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43171 GRAVE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-4006
Mailing Address - Country:US
Mailing Address - Phone:763-228-1225
Mailing Address - Fax:
Practice Address - Street 1:43171 GRAVE LAKE RD
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-4006
Practice Address - Country:US
Practice Address - Phone:763-228-1225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105828225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist