Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225XM0800X | Mental Health | TR00810 | NJ |
N | 225XN1300X | Occupational Therapist - Neurorehabilitation | TR00810 | NJ |
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | TR00810 | NJ |
N | 225XP0200X | Occupational Therapist - Pediatrics | TR00810 | NJ |
NPI | 1285876128 |
---|---|
Provider Name | Ms. Phyllis Lynn Gordon |
First Address | Tenafly, NJ 07670-2707 |
Second Address | Tenafly, NJ 07670-2707 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2009 |
Last Update Date | 19/08/2010 |