Provider Demographics
NPI:1083130264
Name:GORMAN, MICHAELLA MARIE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAELLA
Middle Name:MARIE
Last Name:GORMAN
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-2242
Mailing Address - Country:US
Mailing Address - Phone:402-689-1191
Mailing Address - Fax:
Practice Address - Street 1:2600 ARBORETUM DR
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3501
Practice Address - Country:US
Practice Address - Phone:402-293-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47600515869Medicaid