MEDICARE: WILLIAM THOMAS GORHAM JR.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	251S00000X	Community/Behavioral Health Agency	NC
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	NC
3	320800000X	Mental Illness Community Based Residential Treatment Facility	NC
4	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	NC

General Provider Information

NPI Number	:	1568230902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM THOMAS GORHAM JR.

Provider Business Mailing Address
First Line	:	878 W STAR ST
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27834-0844
Country	:	US
Telephone Number	:	252-417-6829
Fax Number	:

Provider Business Practice Location Address
First Line	:	878 W STAR ST
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27834-0844
Country	:	US
Telephone Number	:	252-417-6829
Fax Number	:

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

Provider Enumeration Date	:	12/14/2023
Last Update Date	:	12/14/2023

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