Provider Demographics
NPI:1699151258
Name:GORHAM, CHELSEY LAYNE
Entity type:Individual
Prefix:
First Name:CHELSEY
Middle Name:LAYNE
Last Name:GORHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13121 EASTPOINT PARK BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4192
Mailing Address - Country:US
Mailing Address - Phone:502-262-8767
Mailing Address - Fax:
Practice Address - Street 1:13121 EASTPOINT PARK BLVD STE F
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4192
Practice Address - Country:US
Practice Address - Phone:502-612-9129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1427106H00000X
IN350019282A106H00000X
106H00000X
KY167133106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7101039050Medicaid