Provider Demographics
NPI:1841215415
Name:GORMELY, TERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GORMELY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:A
Other - Last Name:DEXTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 422
Mailing Address - Street 2:ACADIA HOSPITAL CORP
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0422
Mailing Address - Country:US
Mailing Address - Phone:207-973-6100
Mailing Address - Fax:207-973-6109
Practice Address - Street 1:268 STILLWATER AVENUE
Practice Address - Street 2:ACADIA HOSPITAL CORP
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-973-6100
Practice Address - Fax:207-973-6109
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME2526671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical