Provider Demographics
NPI:1386257665
Name:GORNIAK, AMY NICOLE (MA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:GORNIAK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:NICOLE
Other - Last Name:GILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:8535 TOM SLICK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3367
Mailing Address - Country:US
Mailing Address - Phone:210-616-0300
Mailing Address - Fax:
Practice Address - Street 1:8535 TOM SLICK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3367
Practice Address - Country:US
Practice Address - Phone:210-616-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX36288103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health