MEDICARE: MR. KELLY GOFORTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	105429	KY

General Provider Information

NPI Number	:	1194858571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KELLY GOFORTH

Provider Business Mailing Address
First Line	:	101 W MUHAMMAD ALI BLVD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-1423
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4710 CHAMPIONS TRACE LN STE 107
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-4490
Country	:	US
Telephone Number	:	502-589-8600
Fax Number	:	502-589-8771

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	06/03/2016

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