Provider Demographics
NPI:1194007880
Name:KATHLEEN GORMAN-EZELL, PH.D, LISW, LLC
Entity type:Organization
Organization Name:KATHLEEN GORMAN-EZELL, PH.D, LISW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAN-EZELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, PHD, LISW-S
Authorized Official - Phone:419-344-9940
Mailing Address - Street 1:3323 WINDY FOREST LN
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-7381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:499 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-6605
Practice Address - Country:US
Practice Address - Phone:614-745-9484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0700024-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty