Provider Demographics
NPI:1265786891
Name:GORMAN, JERAMIE SOUSA (PLPC)
Entity type:Individual
Prefix:MR
First Name:JERAMIE
Middle Name:SOUSA
Last Name:GORMAN
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 HARMONY RD
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:MO
Mailing Address - Zip Code:65746-7223
Mailing Address - Country:US
Mailing Address - Phone:417-935-2799
Mailing Address - Fax:
Practice Address - Street 1:104 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3301
Practice Address - Country:US
Practice Address - Phone:417-588-5885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037683101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health