Provider Demographics
NPI:1093698490
Name:GORMICAN, ELLEN THERESE (LICSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:THERESE
Last Name:GORMICAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3236 LONGFELLOW AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3805
Mailing Address - Country:US
Mailing Address - Phone:612-807-6872
Mailing Address - Fax:
Practice Address - Street 1:3236 LONGFELLOW AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3805
Practice Address - Country:US
Practice Address - Phone:612-807-6872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30671103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical