MEDICARE: NICOLE HOLLY GORDON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	93715	CA

General Provider Information

NPI Number	:	1265395768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE HOLLY GORDON

Provider Business Mailing Address
First Line	:	1134 1/2 N MARYLAND AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91207-1607
Country	:	US
Telephone Number	:	310-696-9860
Fax Number	:

Provider Business Practice Location Address
First Line	:	1134 1/2 N MARYLAND AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91207-1607
Country	:	US
Telephone Number	:	310-696-9860
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2025
Last Update Date	:	12/03/2025

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