Provider Demographics
NPI:1689490864
Name:GORDON CAMPOS, KATHERINE STELLA
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:STELLA
Last Name:GORDON CAMPOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 N LOOP 336 W APT 5311
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3470
Mailing Address - Country:US
Mailing Address - Phone:936-276-9647
Mailing Address - Fax:
Practice Address - Street 1:127 MEDICAL PARK LN
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4972
Practice Address - Country:US
Practice Address - Phone:936-294-0283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2142543225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant