Provider Demographics
NPI:1699165001
Name:GORDON-WHITE, ANGELLA
Entity type:Individual
Prefix:
First Name:ANGELLA
Middle Name:
Last Name:GORDON-WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELLA
Other - Middle Name:M
Other - Last Name:GORDON-CARTHY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8410 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8410 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2012
Practice Address - Country:US
Practice Address - Phone:856-256-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007605224Z00000X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant