Provider Demographics
NPI:1376195024
Name:GORMAN, REGINA (MASTER DEGREE)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MASTER DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER PH
Mailing Address - Street 2:OFF HIGHWAY 191, PHS/IHS DRIVE
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503
Mailing Address - Country:US
Mailing Address - Phone:928-674-7387
Mailing Address - Fax:928-674-7600
Practice Address - Street 1:OFF HIGHWAY 191, PHS/IHS DRIVE
Practice Address - Street 2:PO DRAWER PH
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7378
Practice Address - Fax:928-674-7600
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC-15475101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)