Provider Demographics
NPI:1669032140
Name:GORMAN, GEORGIA REMI (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:REMI
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:GEORGIA
Other - Middle Name:REMI
Other - Last Name:LOCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6300 RIDGLEA PL STE 617
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5732
Mailing Address - Country:US
Mailing Address - Phone:817-262-3773
Mailing Address - Fax:
Practice Address - Street 1:6300 RIDGLEA PL STE 617
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5732
Practice Address - Country:US
Practice Address - Phone:817-262-3773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist