Provider Demographics
NPI:1316176209
Name:GORDON, ERIC L (MS CCC/SLP)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:L
Last Name:GORDON
Suffix:
Gender:M
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9033
Mailing Address - Country:US
Mailing Address - Phone:812-796-9029
Mailing Address - Fax:812-796-9029
Practice Address - Street 1:4604 LAKE FOREST DR
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-9033
Practice Address - Country:US
Practice Address - Phone:812-796-9029
Practice Address - Fax:812-796-9029
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002489235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist