Provider Demographics
NPI:1487754313
Name:FENNELL-GORDON, COLLEEN M (PT)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:M
Last Name:FENNELL-GORDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:FENNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:133 AVIATION RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-8206
Mailing Address - Country:US
Mailing Address - Phone:518-798-0170
Mailing Address - Fax:
Practice Address - Street 1:133 AVIATION RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-8206
Practice Address - Country:US
Practice Address - Phone:518-798-0170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005890-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00752456Medicaid