Provider Demographics
NPI:1477663573
Name:GORMAN, MARY SLOAN (MSW LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:SLOAN
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:MS
Other - First Name:SLOAN
Other - Middle Name:
Other - Last Name:GORMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:328 HOWARD ST APT A
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2721
Mailing Address - Country:US
Mailing Address - Phone:707-789-7894
Mailing Address - Fax:
Practice Address - Street 1:205 KELLER ST STE 202C
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2878
Practice Address - Country:US
Practice Address - Phone:707-789-7894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT005502OtherSTATE OF CT LICENSE