Provider Demographics
NPI:1669714887
Name:GORHAM, TANIA (MS, LMFT, QS)
Entity type:Individual
Prefix:MRS
First Name:TANIA
Middle Name:
Last Name:GORHAM
Suffix:
Gender:F
Credentials:MS, LMFT, QS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CROCKETT BLVD STE 540465
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4393
Mailing Address - Country:US
Mailing Address - Phone:321-514-4102
Mailing Address - Fax:
Practice Address - Street 1:2100 LEE RD STE A
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1862
Practice Address - Country:US
Practice Address - Phone:407-644-7593
Practice Address - Fax:407-628-0773
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3161106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
101YM0800XOtherNONE