Provider Demographics
NPI:1750452025
Name:GORMAN, MARK W (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:GORMAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3233 E MEMORIAL RD
Mailing Address - Street 2:STE. 110
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-7082
Mailing Address - Country:US
Mailing Address - Phone:405-608-0545
Mailing Address - Fax:405-286-0057
Practice Address - Street 1:3233 E MEMORIAL RD
Practice Address - Street 2:STE. 110
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-7082
Practice Address - Country:US
Practice Address - Phone:405-608-0545
Practice Address - Fax:405-286-0057
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1164101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1164OtherLICENSE NUMBER, LPC.