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General NPI Number Information
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NPI Number | 1598955577
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Entity Type | Organization
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Legal Business Name | MICHAEL GORMLEY LP
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Dates
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Enumeration Date | 07/26/2007
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Last Update Date | 07/26/2007
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Provider Practice Location Address
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Address Line | 610 CHESTNUT ST
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City | GLENCOE
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State | MN
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Zip | 55336-1028
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Country | US
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Telephone | 320-864-4725
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Fax |
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Provider Business Mailing Address
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Address Line | 610 CHESTNUT ST
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City | GLENCOE
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State | MN
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Zip | 55336-1028
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Country | US
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Telephone | 320-864-4725
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Fax |
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Authorized Official
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Title or Position | BILLING OFFICE MGR
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Name | JAN WIRTZ
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Credential |
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Telephone | 952-442-7015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP0509
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License Number State | MN
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