Provider Demographics
NPI:1437493103
Name:GORMAN, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:952 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2308
Practice Address - Country:US
Practice Address - Phone:510-292-8841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10030235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#174400000XOtherOTHER SERVICE PROVIDERS