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General NPI Number Information
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NPI Number | 1003352055
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Entity Type | Individual
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Provider Name | ADAM GORDON
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Gender | Male
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Dates
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Enumeration Date | 01/15/2017
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Last Update Date | 01/15/2017
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Provider Practice Location Address
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Address Line | 1940 BONITA DR
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City | APTOS
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State | CA
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Zip | 95003-5524
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Country | US
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Telephone | 831-684-1804
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Fax |
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Provider Business Mailing Address
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Address Line | 84 ROBAK DR
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City | WATSONVILLE
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State | CA
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Zip | 95076-1642
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Country | US
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Telephone | 617-331-3786
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | OT16180
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License Number State | CA
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