Provider Demographics
NPI:1750925301
Name:GORMLY, LAURA J (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:J
Last Name:GORMLY
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 211TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3248
Mailing Address - Country:US
Mailing Address - Phone:718-309-6883
Mailing Address - Fax:
Practice Address - Street 1:4560 211TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3248
Practice Address - Country:US
Practice Address - Phone:718-309-6883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR309992-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty