Provider Demographics
NPI:1285876128
Name:GORDON, PHYLLIS LYNN (MSOTR)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:LYNN
Last Name:GORDON
Suffix:
Gender:F
Credentials:MSOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BYRNE LN
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2707
Mailing Address - Country:US
Mailing Address - Phone:201-569-6288
Mailing Address - Fax:201-227-9267
Practice Address - Street 1:10 BYRNE LN
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-2707
Practice Address - Country:US
Practice Address - Phone:201-569-6288
Practice Address - Fax:201-227-9267
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTR00810225XM0800X, 225XN1300X, 225XP0019X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics