Healthcare Provider Details

I. General information

NPI: 1225430333
Provider Name (Legal Business Name): CAROLYN MAY GORMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS CAROLYN MAY BURGESS

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 WEST ST UNIT B
PLANTSVILLE CT
06479-1140
US

IV. Provider business mailing address

133 HIGH ST
WALLINGFORD CT
06492-3169
US

V. Phone/Fax

Practice location:
  • Phone: 203-819-0789
  • Fax:
Mailing address:
  • Phone: 860-834-1312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002318
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number002318
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: