Healthcare Provider Details

I. General information

NPI: 1235176538
Provider Name (Legal Business Name): MARY ELLEN GORMAN RN CS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 WASHINGTON ST SUITE 210
WELLESLEY MA
02481
US

IV. Provider business mailing address

42 WASHINGTON ST SUITE 210
WELLESLEY MA
02481
US

V. Phone/Fax

Practice location:
  • Phone: 781-431-1990
  • Fax: 781-416-4321
Mailing address:
  • Phone: 781-431-1990
  • Fax: 781-416-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number161364
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: