Healthcare Provider Details

I. General information

NPI: 1487442372
Provider Name (Legal Business Name): KRISTEN RACHELLE GORDON PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16030 VENTURA BLVD STE 450
ENCINO CA
91436-2764
US

IV. Provider business mailing address

655 OAK VALLEY PKWY
BEAUMONT CA
92223-1455
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-1977
  • Fax:
Mailing address:
  • Phone: 951-203-5923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number292467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: