Healthcare Provider Details

I. General information

NPI: 1689015067
Provider Name (Legal Business Name): ASHLEY BLAKE GORDON N.D., LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 WESTBANK DR
AUSTIN TX
78746-4454
US

IV. Provider business mailing address

7310 MANCHACA RD #150939
AUSTIN TX
78715-5001
US

V. Phone/Fax

Practice location:
  • Phone: 512-327-8877
  • Fax: 512-327-0388
Mailing address:
  • Phone: 512-222-8515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number099.0082246
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01608
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: