Healthcare Provider Details

I. General information

NPI: 1265377048
Provider Name (Legal Business Name): COLLEEN GAVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S. MAIN ST
ANGELS CAMP CA
95222
US

IV. Provider business mailing address

PO BOX 7000/21
ANGELS CAMP CA
95222
US

V. Phone/Fax

Practice location:
  • Phone: 209-736-2507
  • Fax: 209-736-8367
Mailing address:
  • Phone: 209-736-2507
  • Fax: 209-736-8367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: