Provider Demographics
NPI:1750391785
Name:GORZELIC, MARY LOU (LCSW)
Entity type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:GORZELIC
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 TENNESSEE DR
Mailing Address - Street 2:
Mailing Address - City:OREFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:18069-3038
Mailing Address - Country:US
Mailing Address - Phone:610-737-5818
Mailing Address - Fax:610-253-7062
Practice Address - Street 1:105 W BROAD ST FL 2
Practice Address - Street 2:
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-1916
Practice Address - Country:US
Practice Address - Phone:610-737-5818
Practice Address - Fax:610-253-7062
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0154281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102542171Medicaid