Provider Demographics
NPI:1063298909
Name:GORMAN, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2398 WEST SPRING DRIVE APT. C203
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721
Mailing Address - Country:US
Mailing Address - Phone:620-215-9732
Mailing Address - Fax:
Practice Address - Street 1:5006 N 22ND ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-5116
Practice Address - Country:US
Practice Address - Phone:417-429-2412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023035545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist