Provider Demographics
NPI:1194297408
Name:GORDON, CRISTINA D (CCC - SLP)
Entity type:Individual
Prefix:MRS
First Name:CRISTINA
Middle Name:D
Last Name:GORDON
Suffix:
Gender:F
Credentials:CCC - SLP
Other - Prefix:MS
Other - First Name:CRISTINA
Other - Middle Name:
Other - Last Name:GIACOBBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC - SLP
Mailing Address - Street 1:1337 BROOKVIEW STATION RD
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-3118
Mailing Address - Country:US
Mailing Address - Phone:516-307-6611
Mailing Address - Fax:
Practice Address - Street 1:4 FAIRCHILD SQ
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-1254
Practice Address - Country:US
Practice Address - Phone:518-664-5066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY029508235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program