Provider Demographics
NPI:1558015479
Name:GORMAN, SHANNON (LMSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1182 CHENANGO ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-1653
Mailing Address - Country:US
Mailing Address - Phone:607-772-6904
Mailing Address - Fax:607-722-4123
Practice Address - Street 1:1182 CHENANGO ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1653
Practice Address - Country:US
Practice Address - Phone:607-772-6904
Practice Address - Fax:607-722-4123
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057587104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02997780Medicaid