Provider Demographics
NPI:1073606828
Name:GORMAN, MARY (PT/LMT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:PT/LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S PACIFIC HWY
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-6650
Mailing Address - Country:US
Mailing Address - Phone:541-535-7019
Mailing Address - Fax:541-512-8717
Practice Address - Street 1:2205 ASHLAND ST STE 204
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1971
Practice Address - Country:US
Practice Address - Phone:541-482-0242
Practice Address - Fax:541-482-0231
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR084229000OtherBLUECROSS BLUESHIELD
OR299328Medicaid
OR299328Medicaid