Provider Demographics
NPI:1922302017
Name:DORMAN, GREGORY G (BA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:G
Last Name:DORMAN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 HAZEL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-1630
Mailing Address - Country:US
Mailing Address - Phone:541-734-3953
Mailing Address - Fax:
Practice Address - Street 1:1911 HAZEL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-1630
Practice Address - Country:US
Practice Address - Phone:541-734-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health