Provider Demographics
NPI:1750346920
Name:GORDON, MICHELE MARY (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARY
Last Name:GORDON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 GOLDEN RIDGE RD STE 130
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-9541
Mailing Address - Country:US
Mailing Address - Phone:303-275-2190
Mailing Address - Fax:
Practice Address - Street 1:660 GOLDEN RIDGE RD STE 130
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-9541
Practice Address - Country:US
Practice Address - Phone:303-275-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6222225XH1200X
OR1075776225X00000X
NC6729225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC346512OtherMEDICARE PTAN