Healthcare Provider Details

I. General information

NPI: 1972843019
Provider Name (Legal Business Name): JOHN PHILLIP GORMAN III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 VALLEY ST
WILLIMANTIC CT
06226-1901
US

IV. Provider business mailing address

433 VALLEY ST
WILLIMANTIC CT
06226-1901
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-7200
  • Fax: 860-456-7202
Mailing address:
  • Phone: 860-456-7200
  • Fax: 860-456-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: