Basic Information
| Provider Information | |||||||||
| NPI: | 1033654462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDILLO | ||||||||
| FirstName: | ANDRES | ||||||||
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| Credential: | M.S CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3823 E STATE ROAD 64 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342089041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613057975 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3823 E STATE ROAD 64 FL 34208 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342089041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417455111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2016 | ||||||||
| LastUpdateDate: | 03/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA15492 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 019549700 | 05 | FL | MEDICAID |