Basic Information
| Provider Information | |||||||||
| NPI: | 1023118031 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GORDON | ||||||||
| FirstName: | CYNTHIA | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11901 TOEPPERWEIN RD | ||||||||
| Address2: | SUITE 1106 | ||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106511900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11901 TOEPPERWEIN RD | ||||||||
| Address2: | SUITE 1106 | ||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106511900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1448 | OK | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 106889 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200069770A | 05 | TX | MEDICAID | 200069770 A | 05 | OK | MEDICAID |