Healthcare Provider Details

I. General information

NPI: 1881509859
Provider Name (Legal Business Name): MS. DIANA MARGARET GORHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2026
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 E LIBERTY ST
CHARLES TOWN WV
25414-1824
US

IV. Provider business mailing address

533 S SEMINARY ST
CHARLES TOWN WV
25414-1348
US

V. Phone/Fax

Practice location:
  • Phone: 304-725-7176
  • Fax:
Mailing address:
  • Phone: 304-433-5638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3252
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: