=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942503925
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN GORMAN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2010
-----------------------------------------------------
Last Update Date | 12/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 MORRIS AVE SUITE 214
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834-1368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-874-8662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 WHIPPOORWILL LN
-----------------------------------------------------
City | ROCKAWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07866-4222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 220-187-4866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. SUSAN GORMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-874-8662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 37PC00390700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------