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General NPI Number Information
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NPI Number | 1194007880
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Entity Type | Organization
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Legal Business Name | KATHLEEN GORMAN-EZELL, PH.D, LISW, LLC
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Dates
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Enumeration Date | 09/19/2011
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Last Update Date | 09/19/2011
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Provider Practice Location Address
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Address Line | 499 VILLAGE PARK DR
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City | POWELL
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State | OH
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Zip | 43065-6605
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Country | US
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Telephone | 614-745-9484
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Fax |
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Provider Business Mailing Address
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Address Line | 3323 WINDY FOREST LN
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City | POWELL
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State | OH
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Zip | 43065-7381
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KATHLEEN GORMAN-EZELL
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Credential | MSW, PHD, LISW-S
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Telephone | 419-344-9940
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I.0700024-SUPV
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License Number State | OH
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