Provider Demographics
NPI:1982729240
Name:GORMAN, VIRGINIA I (LCAS)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:I
Last Name:GORMAN
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 NE 9TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-6626
Mailing Address - Country:US
Mailing Address - Phone:910-278-3355
Mailing Address - Fax:
Practice Address - Street 1:125 NE 9TH ST
Practice Address - Street 2:
Practice Address - City:OAK ISLAND
Practice Address - State:NC
Practice Address - Zip Code:28465-6626
Practice Address - Country:US
Practice Address - Phone:910-278-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC353101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111756Medicaid