MEDICARE: DENNIS R. GOURLEY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CW013873	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447346234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS R. GOURLEY LCSW

Provider Business Mailing Address
First Line	:	480 PIERCE STREET
Second Line	:	SUITE 112
City	:	KINGSTON
State	:	PA
Zip	:	18704-5512
Country	:	US
Telephone Number	:	570-714-0890
Fax Number	:	570-714-0890

Provider Business Practice Location Address
First Line	:	480 PIERCE STREET
Second Line	:	SUITE 112
City	:	KINGSTON
State	:	PA
Zip	:	18704-5512
Country	:	US
Telephone Number	:	570-714-0890
Fax Number	:	570-714-0890

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	04/16/2015

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