Healthcare Provider Details

I. General information

NPI: 1104087832
Provider Name (Legal Business Name): ELIZABETH GORDON DENSON PT ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH LEIGH GORDON

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 DAIRY LANE WOODMONT CENTER
FREDRICKSBURG VA
22405
US

IV. Provider business mailing address

5059 DAWN COURT
WARRENTON VA
20187
US

V. Phone/Fax

Practice location:
  • Phone: 540-371-9414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306000267
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: