Provider Demographics
NPI:1770104267
Name:GORSCH, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GORSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 W UNIVERSITY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2970
Mailing Address - Country:US
Mailing Address - Phone:580-924-7331
Mailing Address - Fax:580-924-7332
Practice Address - Street 1:2425 W UNIVERSITY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2970
Practice Address - Country:US
Practice Address - Phone:580-924-7331
Practice Address - Fax:580-924-7332
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100728830Medicaid