Provider Demographics
NPI:1245093962
Name:GORMAN, BRENDA T
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:T
Last Name:GORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 JORDAN LN
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502-1313
Mailing Address - Country:US
Mailing Address - Phone:917-806-4780
Mailing Address - Fax:
Practice Address - Street 1:15 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2152
Practice Address - Country:US
Practice Address - Phone:914-347-5990
Practice Address - Fax:914-347-5236
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY738723174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist