Provider Demographics
NPI:1114258670
Name:GORMAN, TERRI L (LCSW)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:L
Last Name:GORMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681
Mailing Address - Street 2:
Mailing Address - City:PENROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81240-0681
Mailing Address - Country:US
Mailing Address - Phone:719-784-7522
Mailing Address - Fax:719-784-7522
Practice Address - Street 1:1335 PHAY AVE
Practice Address - Street 2:SUITE H
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2334
Practice Address - Country:US
Practice Address - Phone:719-784-7522
Practice Address - Fax:719-784-7522
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-23
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO993001101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional