Provider Demographics
NPI:1740168897
Name:GORDON, ANDREA MARJEAN (LMT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARJEAN
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 MINNEAPOLIS ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3136
Mailing Address - Country:US
Mailing Address - Phone:334-235-1134
Mailing Address - Fax:
Practice Address - Street 1:1820 GLYNWOOD DR STE D
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-5533
Practice Address - Country:US
Practice Address - Phone:334-235-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501001907225700000X
AL6725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist