=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790416204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIA O'GORMAN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2022
-----------------------------------------------------
Last Update Date | 06/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7100 RAWSON RD
-----------------------------------------------------
City | CUBA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14727-9281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-610-6762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 W SENECA ST STE 205
-----------------------------------------------------
City | MANLIUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13104-2480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-653-0229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 092220
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------