Provider Demographics
NPI:1679587083
Name:GORNER, LEO (PT)
Entity type:Individual
Prefix:MR
First Name:LEO
Middle Name:
Last Name:GORNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 REDMILE CT
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3538
Mailing Address - Country:US
Mailing Address - Phone:410-960-7900
Mailing Address - Fax:
Practice Address - Street 1:613 HAMMONDS LN
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MD
Practice Address - Zip Code:21225-3351
Practice Address - Country:US
Practice Address - Phone:410-636-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400654200Medicaid
MD54478442OtherBLUE CROSS BLUE SHIELD
MD54478442OtherBLUE CROSS BLUE SHIELD
MD406MF348Medicare ID - Type Unspecified