Provider Demographics
NPI:1891849188
Name:HONNERT-GORMAN, MARY (LSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:HONNERT-GORMAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 EAST DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-1747
Mailing Address - Country:US
Mailing Address - Phone:937-299-3752
Mailing Address - Fax:
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:SUITE 111
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408-1445
Practice Address - Country:US
Practice Address - Phone:937-228-0579
Practice Address - Fax:937-228-0592
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS105161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical