Basic Information
| Provider Information | |||||||||
| NPI: | 1194186692 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | YOLANDA | ||||||||
| MiddleName: | MCCLOUD | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 WELLMORE DR | ||||||||
| Address2: | |||||||||
| City: | TEGA CAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297080124 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 WELLMORE DR | ||||||||
| Address2: | |||||||||
| City: | TEGA CAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297080124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038357000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2016 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 3559 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.