Provider Demographics
NPI:1720203573
Name:GORGOL, MARY B (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:GORGOL
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4827 E 72ND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2501
Mailing Address - Country:US
Mailing Address - Phone:317-435-6149
Mailing Address - Fax:317-570-3699
Practice Address - Street 1:4827 E 72ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2501
Practice Address - Country:US
Practice Address - Phone:317-435-6149
Practice Address - Fax:317-570-3699
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002678A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200716360AOtherPROVIDER NUMBER
IN200648660OtherRENDERING PROVIDER NUMBER