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General NPI Number Information
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NPI Number | 1104959626
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Entity Type | Individual
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Provider Name | JANE-ELLEN MARY GORMAN PH.D.
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Gender | Female
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Dates
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Enumeration Date | 03/13/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 340 RANCHEROS DR
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City | SAN MARCOS
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State | CA
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Zip | 92069-2900
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Country | US
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Telephone | 767-075-2490
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Fax | 760-752-4924
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Provider Business Mailing Address
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Address Line | 340 RANCHEROS DR
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City | SAN MARCOS
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State | CA
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Zip | 92069-2900
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Country | US
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Telephone | 767-075-2490
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Fax | 760-752-4924
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY 14991
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License Number State | CA
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