Healthcare Provider Details

I. General information

NPI: 1780524975
Provider Name (Legal Business Name): CAROL ANN GORDON BSC OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 RAVOLI DR
PACIFIC PALISADES CA
90272
US

IV. Provider business mailing address

1080 RAVOLI DR
PACIFIC PALISADES CA
90272-3917
US

V. Phone/Fax

Practice location:
  • Phone: 310-230-1775
  • Fax: 310-230-1874
Mailing address:
  • Phone: 310-230-1775
  • Fax: 310-230-1874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberAA455014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: