Provider Demographics
NPI:1336587831
Name:GORMAN, THERESA L
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:L
Last Name:GORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:L
Other - Last Name:PERCY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1021 FRAN LIN PKWY
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10829 S WESTERN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3229
Practice Address - Country:US
Practice Address - Phone:773-779-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.296842163WC0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse