Provider Demographics
NPI:1912719428
Name:GORDON, MCKENZIE (CT)
Entity type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22001 FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4819
Mailing Address - Country:US
Mailing Address - Phone:216-932-2800
Mailing Address - Fax:
Practice Address - Street 1:3421 SNOW RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-2960
Practice Address - Country:US
Practice Address - Phone:440-340-4654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2405768-TRNE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program