Provider Demographics
NPI:1871039107
Name:LORMIS, JEREMY (PHD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LORMIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 BONNIE REED PSGE
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:GA
Mailing Address - Zip Code:31320-4925
Mailing Address - Country:US
Mailing Address - Phone:912-980-5074
Mailing Address - Fax:
Practice Address - Street 1:108 DUNCRAIG DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-3335
Practice Address - Country:US
Practice Address - Phone:434-664-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006916101Y00000X, 101YM0800X, 101YP2500X
GALPC009273101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health