Provider Demographics
NPI:1861767543
Name:GOURDINE, DENISE YVONNE (OTRL)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:YVONNE
Last Name:GOURDINE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 FLATBUSH AVE
Mailing Address - Street 2:APARTMENT # A1905
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-3276
Mailing Address - Country:US
Mailing Address - Phone:718-253-4047
Mailing Address - Fax:
Practice Address - Street 1:1957 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-1531
Practice Address - Country:US
Practice Address - Phone:718-941-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAA607549225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist