Provider Demographics
NPI:1811392798
Name:GORMLEY, LEO (CRADC)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:GORMLEY
Suffix:
Gender:M
Credentials:CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 OLIVE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2303
Mailing Address - Country:US
Mailing Address - Phone:314-206-3700
Mailing Address - Fax:
Practice Address - Street 1:6763 PAGE AVE # MO
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63133-1635
Practice Address - Country:US
Practice Address - Phone:314-206-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MO11787101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)