Provider Demographics
NPI:1427584275
Name:GORMAN, MEG (MSED)
Entity Type:Individual
Prefix:
First Name:MEG
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-5324
Mailing Address - Country:US
Mailing Address - Phone:518-271-6777
Mailing Address - Fax:
Practice Address - Street 1:435 4TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-5324
Practice Address - Country:US
Practice Address - Phone:518-271-6777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1125330172405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional