Basic Information
| Provider Information | |||||||||
| NPI: | 1386707628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | S.L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | HTN, CLIENT ACCOUNTING | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694395 | ||||||||
| FaxNumber: | 8175694517 | ||||||||
| Practice Location | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | HTN, CLIENT ACCOUNTING | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694395 | ||||||||
| FaxNumber: | 8175694517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 18251 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 005744001 | 05 | TX | MEDICAID | 8T1030 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |