Provider Demographics
NPI:1467085613
Name:GORMAN, JAMES RYAN (SAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RYAN
Last Name:GORMAN
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1150
Mailing Address - Country:US
Mailing Address - Phone:414-775-2500
Mailing Address - Fax:414-301-9328
Practice Address - Street 1:1333 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-1150
Practice Address - Country:US
Practice Address - Phone:414-775-2500
Practice Address - Fax:414-301-9328
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19103101YA0400X
WI16552101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)