Basic Information
Provider Information
NPI: 1003001355
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GORNING
FirstName: KRISTIN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MA DT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 715 W ARMITAGE AVE # 2
Address2:  
City: CHICAGO
State: IL
PostalCode: 606144409
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 715 W ARMITAGE AVE # 2
Address2:  
City: CHICAGO
State: IL
PostalCode: 606144409
CountryCode: US
TelephoneNumber: 7734580951
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/10/2007
LastUpdateDate: 09/10/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
222Q00000X  Y Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist 

No ID Information.


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