Provider Demographics
NPI:1215582747
Name:GORMAN, MADISON ALYSE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ALYSE
Last Name:GORMAN
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 1:229 LOWER SHEEP PASTURE RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1866
Mailing Address - Country:US
Mailing Address - Phone:631-495-6483
Mailing Address - Fax:
Practice Address - Street 1:252 ISLIP AVE # B
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3015
Practice Address - Country:US
Practice Address - Phone:631-581-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist