Basic Information
| Provider Information | |||||||||
| NPI: | 1356333595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LADC ACADC CCGC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13522 BIRCHWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681374223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028719028 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 515 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123221407 | ||||||||
| FaxNumber: | 7123226833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CCGC 021 | NE | X | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | LADC | NE | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | ACADC | IA | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.