Provider Demographics
NPI:1043047269
Name:GORMAN, DEVON KB
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:KB
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:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-0052
Mailing Address - Country:US
Mailing Address - Phone:480-401-6166
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 457
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505-0457
Practice Address - Country:US
Practice Address - Phone:928-755-4586
Practice Address - Fax:928-755-4747
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22971101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health