Provider Demographics
NPI:1164076097
Name:GORHAM, JILLEEN ELIZABETH (MS, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:JILLEEN
Middle Name:ELIZABETH
Last Name:GORHAM
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 IDLEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-3010
Mailing Address - Country:US
Mailing Address - Phone:315-559-4303
Mailing Address - Fax:
Practice Address - Street 1:721 IDLEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-3010
Practice Address - Country:US
Practice Address - Phone:315-559-4303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009390101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty