Provider Demographics
NPI:1720884422
Name:GORDON, ROXANNE LANE (CLD, CMT)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:LANE
Last Name:GORDON
Suffix:
Gender:
Credentials:CLD, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24345 MULHOLLAND HWY # B
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-2319
Mailing Address - Country:US
Mailing Address - Phone:323-371-9314
Mailing Address - Fax:
Practice Address - Street 1:24345 MULHOLLAND HWY # B
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-2319
Practice Address - Country:US
Practice Address - Phone:323-371-9314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-22
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X, 374J00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist