MEDICARE: MS. ANN E GORDON M.A., CCC/SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	000469-1	NY

General Provider Information

NPI Number	:	1770531857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANN E GORDON M.A., CCC/SLP

Provider Business Mailing Address
First Line	:	17 MILLS LN
Second Line	:
City	:	EAST SETAUKET
State	:	NY
Zip	:	11733-3805
Country	:	US
Telephone Number	:	631-751-3838
Fax Number	:	631-751-3767

Provider Business Practice Location Address
First Line	:	207 HALLOCK RD
Second Line	:	SUITE 6
City	:	STONY BROOK
State	:	NY
Zip	:	11790-3033
Country	:	US
Telephone Number	:	631-751-3838
Fax Number	:	631-751-3767

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/08/2007

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