MEDICARE: NANCY H GORDON MA, 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	2202002705	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	257110	OTHER	VA	MAMSI

General Provider Information

NPI Number	:	1780698589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY H GORDON MA, CCC-SLP

Provider Business Mailing Address
First Line	:	906 TRAILVIEW BLVD. SE
Second Line	:	SUITE A
City	:	LEESBURG
State	:	VA
Zip	:	20175
Country	:	US
Telephone Number	:	703-777-0561
Fax Number	:	703-737-8235

Provider Business Practice Location Address
First Line	:	906 TRAILVIEW BLVD SE
Second Line	:	SUITE A
City	:	LEESBURG
State	:	VA
Zip	:	20175-4415
Country	:	US
Telephone Number	:	703-777-0561
Fax Number	:	703-737-8235

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

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	09/12/2007

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