Provider Demographics
NPI:1235176538
Name:GORMAN, MARY ELLEN (RN CS MS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:GORMAN
Suffix:
Gender:F
Credentials:RN CS MS
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Mailing Address - Street 1:42 WASHINGTON ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481
Mailing Address - Country:US
Mailing Address - Phone:781-431-1990
Mailing Address - Fax:781-416-4321
Practice Address - Street 1:42 WASHINGTON ST
Practice Address - Street 2:SUITE 210
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-431-1990
Practice Address - Fax:781-416-4321
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA161364163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN0802OtherBLUE CROSS
MA478906OtherTUFTS
MAPN0802OtherBLUE CROSS
P91195Medicare UPIN