Provider Demographics
NPI:1396118659
Name:GHORMLEY, DUSTIN ARIEL (LPT)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:ARIEL
Last Name:GHORMLEY
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E CYPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6806
Mailing Address - Country:US
Mailing Address - Phone:805-864-1940
Mailing Address - Fax:805-865-1954
Practice Address - Street 1:401 E CYPRESS AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6806
Practice Address - Country:US
Practice Address - Phone:805-864-1940
Practice Address - Fax:805-865-1954
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38175167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician