Provider Demographics
NPI:1538624721
Name:GORDON, MICHAEL (ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-0776
Mailing Address - Country:US
Mailing Address - Phone:802-893-7427
Mailing Address - Fax:802-893-7429
Practice Address - Street 1:184 ROUTE 7 S
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:VT
Practice Address - Zip Code:05468-3602
Practice Address - Country:US
Practice Address - Phone:802-893-7427
Practice Address - Fax:802-893-7429
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.01339082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer