Provider Demographics
NPI:1588616916
Name:HERRMANN, GORDON C (LCSW)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:C
Last Name:HERRMANN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9615 E 148TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4360
Mailing Address - Country:US
Mailing Address - Phone:317-587-0500
Mailing Address - Fax:317-674-0059
Practice Address - Street 1:697 PRO-MED LN
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5323
Practice Address - Country:US
Practice Address - Phone:317-574-0055
Practice Address - Fax:317-674-0059
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001015A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100073590AMedicaid
IN100073590AMedicaid