Provider Demographics
NPI:1487062923
Name:GORDON, MELISSA L (OTR)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:GORDON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4083
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-4083
Mailing Address - Country:US
Mailing Address - Phone:970-331-3559
Mailing Address - Fax:
Practice Address - Street 1:2424 DRAW SPUR LANE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620-4083
Practice Address - Country:US
Practice Address - Phone:970-331-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0003883225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95707841Medicaid