Provider Demographics
NPI:1962778431
Name:GORDON, LULA MAE (PTA)
Entity type:Individual
Prefix:MS
First Name:LULA
Middle Name:MAE
Last Name:GORDON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:LULA
Other - Middle Name:MAE
Other - Last Name:GODON-CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2110 SECRETARIET DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-6457
Mailing Address - Country:US
Mailing Address - Phone:281-222-0109
Mailing Address - Fax:
Practice Address - Street 1:2110 SECRETARIET DR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-6457
Practice Address - Country:US
Practice Address - Phone:281-222-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2018206225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant