Provider Demographics
NPI:1639471790
Name:GAYMAN GORESKO, STACY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:GAYMAN GORESKO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8083 MEADOWDALE SQ
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-8597
Mailing Address - Country:US
Mailing Address - Phone:303-652-4950
Mailing Address - Fax:
Practice Address - Street 1:7916 NIWOT RD
Practice Address - Street 2:
Practice Address - City:NIWOT
Practice Address - State:CO
Practice Address - Zip Code:80503-7181
Practice Address - Country:US
Practice Address - Phone:720-290-2707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09977708Medicaid