Healthcare Provider Details

I. General information

NPI: 1962692954
Provider Name (Legal Business Name): SARA GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41945 BIG BEAR BOVD. SUITE222
BIG BEAR LAKE CA
92315
US

IV. Provider business mailing address

PO BOX 2471
BIG BEAR LAKE CA
92315
US

V. Phone/Fax

Practice location:
  • Phone: 909-866-5070
  • Fax: 909-878-3228
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: