Healthcare Provider Details

I. General information

NPI: 1366581738
Provider Name (Legal Business Name): CAROL GORDON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NORTHWESTERN DR SUITE101
BLOOMFIELD CT
06002-3400
US

IV. Provider business mailing address

1 NORTHWESTERN DR SUITE 101
BLOOMFIELD CT
06002-3400
US

V. Phone/Fax

Practice location:
  • Phone: 860-243-6571
  • Fax: 860-243-6579
Mailing address:
  • Phone: 860-243-6571
  • Fax: 860-243-6579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002520
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: