Provider Demographics
NPI:1508519588
Name:GORGONE, NATHAN ROBERT
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ROBERT
Last Name:GORGONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 QUERCUS AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-3621
Mailing Address - Country:US
Mailing Address - Phone:860-617-9709
Mailing Address - Fax:
Practice Address - Street 1:550 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5017
Practice Address - Country:US
Practice Address - Phone:860-870-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty