Provider Demographics
NPI:1588263719
Name:GORMAN, LARAINE L
Entity type:Individual
Prefix:
First Name:LARAINE
Middle Name:L
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 1:20 KING ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4008
Mailing Address - Country:US
Mailing Address - Phone:631-495-6929
Mailing Address - Fax:
Practice Address - Street 1:225 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4822
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician