Provider Demographics
NPI:1336455807
Name:GORIN, AMY A (PHD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:GORIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 MICHELLE LN
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 LEDGEBROOK DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1664
Practice Address - Country:US
Practice Address - Phone:860-634-1925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003020103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth