Basic Information
| Provider Information | |||||||||
| NPI: | 1245389634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'GORMAN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 SENECA ST | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142243433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166775418 | ||||||||
| FaxNumber: | 7166774240 | ||||||||
| Practice Location | |||||||||
| Address1: | 3802 SENECA ST | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142243433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166775418 | ||||||||
| FaxNumber: | 7166774240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 0121001 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 00020912401 | 01 | NY | UNIVERA | OTHER | 6190503 | 01 | NY | INDEPENDENT HEALTH | OTHER | 01617830 | 05 | NY | MEDICAID | 000523348003 | 01 | BLUE CROSS BLUE SHIELD OF | OTHER |