Provider Demographics
NPI:1598904997
Name:GORUM, KATHY (LMT)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:GORUM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-3703
Mailing Address - Country:US
Mailing Address - Phone:575-574-0637
Mailing Address - Fax:
Practice Address - Street 1:1503 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-3703
Practice Address - Country:US
Practice Address - Phone:575-574-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5002OtherNEW MEXICO MASSAGE THERAPY BOARD