Provider Demographics
NPI:1154981967
Name:GORDON, LISA BARBARA (MS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BARBARA
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4259 WOODLAND PARK AVE N APT 3
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7449
Mailing Address - Country:US
Mailing Address - Phone:708-476-0265
Mailing Address - Fax:
Practice Address - Street 1:8301 161ST AVE NE STE 208
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3858
Practice Address - Country:US
Practice Address - Phone:425-882-4347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
WALL60981400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASI60891300OtherINTERIM PERMIT
WALL60981400OtherSPEECH LANGUAGE PATHOLOGIST LICENSE