Provider Demographics
NPI:1003562075
Name:GOSNELL, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:GOSNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11606 MAPLE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2255
Mailing Address - Country:US
Mailing Address - Phone:502-593-4282
Mailing Address - Fax:
Practice Address - Street 1:101 SEXTON WAY
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:KY
Practice Address - Zip Code:40347-7800
Practice Address - Country:US
Practice Address - Phone:859-846-4663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
KY274776225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist