Provider Demographics
NPI:1063872315
Name:GORMLEY, GWEN (LMSW)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:GORMLEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 W HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-1433
Mailing Address - Country:US
Mailing Address - Phone:845-596-7054
Mailing Address - Fax:
Practice Address - Street 1:2817 W GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-1810
Practice Address - Country:US
Practice Address - Phone:845-596-7054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094951-1104100000X
PACW0204911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker