Provider Demographics
NPI:1861627846
Name:GORTNEY, MIRIAM A (CPSTP)
Entity Type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:A
Last Name:GORTNEY
Suffix:
Gender:F
Credentials:CPSTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-4686
Mailing Address - Country:US
Mailing Address - Phone:330-823-5335
Mailing Address - Fax:330-823-9177
Practice Address - Street 1:1207 W STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4686
Practice Address - Country:US
Practice Address - Phone:330-823-5335
Practice Address - Fax:330-823-9177
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0290822Medicaid