MEDICARE: LAHELA L GWYNN CMHC

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	101YM0800X	Mental Health Counselor	10834871-6004	UT

General Provider Information

NPI Number	:	1588306799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAHELA L GWYNN CMHC

Provider Business Mailing Address
First Line	:	472 E BRIGHAM AVE
Second Line	:
City	:	AMERICAN FORK
State	:	UT
Zip	:	84003-1832
Country	:	US
Telephone Number	:	916-224-0476
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 N 200 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84150-9703
Country	:	US
Telephone Number	:	855-537-1000
Fax Number	:

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

Provider Enumeration Date	:	04/08/2022
Last Update Date	:	04/08/2022

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