Provider Demographics
NPI:1942303656
Name:GORMLEY, MARY M (LCADC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:GORMLEY
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17 WESTERN REACH
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5436
Mailing Address - Country:US
Mailing Address - Phone:732-747-3442
Mailing Address - Fax:732-450-2803
Practice Address - Street 1:661 SHREWSBURY AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4134
Practice Address - Country:US
Practice Address - Phone:732-747-3442
Practice Address - Fax:732-450-2803
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00032700101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)