Provider Demographics
NPI:1174725998
Name:GORMAN, MARK J (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:GORMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MASSACHUSETTS GENERAL HOSPITAL
Mailing Address - Street 2:55 FRUIT STREET
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-726-4400
Mailing Address - Fax:
Practice Address - Street 1:51 PERFORMANCE DR.
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189
Practice Address - Country:US
Practice Address - Phone:787-624-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8811103TC0700X, 103TC1900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program