Provider Demographics
NPI:1487313821
Name:GORHAM, KELLY DENISE (LPC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DENISE
Last Name:GORHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 HOLLOW PNE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3982
Mailing Address - Country:US
Mailing Address - Phone:770-940-1792
Mailing Address - Fax:
Practice Address - Street 1:2605 HOLLOW PNE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-3982
Practice Address - Country:US
Practice Address - Phone:770-940-1792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012546101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health