Provider Demographics
NPI:1194121327
Name:GORDON, THERESE (LPN)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 PARKSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-1432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:675 3RD AVE FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5731
Practice Address - Country:US
Practice Address - Phone:646-292-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295218172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker