Healthcare Provider Details

I. General information

NPI: 1407216476
Provider Name (Legal Business Name): JOHN GORIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 S ALEX RD
DAYTON OH
45449-5404
US

IV. Provider business mailing address

1625 S ALEX RD
DAYTON OH
45449-5404
US

V. Phone/Fax

Practice location:
  • Phone: 937-657-9154
  • Fax: 937-949-6154
Mailing address:
  • Phone: 937-657-9154
  • Fax: 937-949-6154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE. 0002873
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0019636
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: