Provider Demographics
NPI:1245389634
Name:O'GORMAN, JOSEPH (PHD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:O'GORMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3433
Mailing Address - Country:US
Mailing Address - Phone:716-677-5418
Mailing Address - Fax:716-677-4240
Practice Address - Street 1:3802 SENECA ST
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3433
Practice Address - Country:US
Practice Address - Phone:716-677-5418
Practice Address - Fax:716-677-4240
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0121001103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00020912401OtherUNIVERA
NY6190503OtherINDEPENDENT HEALTH
NY01617830Medicaid
000523348003OtherBLUE CROSS BLUE SHIELD OF
NY01617830Medicaid
NY00020912401OtherUNIVERA