Provider Demographics
NPI:1033553565
Name:GORMLEY, KEVIN RICHARD (PSYD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD
Last Name:GORMLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 GREENWAY ST NW STE 5
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3557
Mailing Address - Country:US
Mailing Address - Phone:410-760-9079
Mailing Address - Fax:
Practice Address - Street 1:30 GREENWAY ST NW STE 5
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3557
Practice Address - Country:US
Practice Address - Phone:410-760-9079
Practice Address - Fax:410-760-1121
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05041103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical