Healthcare Provider Details

I. General information

NPI: 1386928307
Provider Name (Legal Business Name): NICOLE GORDON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE COLLET

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65422 VAN DYKE AVE SUITE 200
WASHINGTON MI
48095
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TOWNSHIP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 586-935-1100
  • Fax: 586-935-1101
Mailing address:
  • Phone: 586-416-9100
  • Fax: 586-416-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501009680
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: