Healthcare Provider Details

I. General information

NPI: 1003352055
Provider Name (Legal Business Name): ADAM GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2017
Last Update Date: 01/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 BONITA DR
APTOS CA
95003-5524
US

IV. Provider business mailing address

84 ROBAK DR
WATSONVILLE CA
95076-1642
US

V. Phone/Fax

Practice location:
  • Phone: 831-684-1804
  • Fax:
Mailing address:
  • Phone: 617-331-3786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT16180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: