| Doctor Name: | MR. JERAMIE SOUSA GORMAN |
| NPI Number: | 1265786891 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PLPC |
| License Number: | 2012037683 |
| Business Practice Address: | 104 Crescent Dr Lebanon, MO - 655363301 |
| Business Phone Number: | 4175885885 |
| Business Fax Number: | |
| Mailing Address: | 413 Harmony Rd, SEYMOUR |
| State: | MO |
| Postal Code: | 657467223 |
| Phone Number: | 4179352799 |
| Fax Number: | |
| NPI Enumeration Date: | 11/05/2012 |
| NPI Last Update Date: | 11/05/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101Y00000X |
| License Number: | 2012037683 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider who is trained and educated in the performance of behavior health services through interpersonal communications and analysis. Training and education at the specialty level usually requires a master |