Healthcare Provider Details

I. General information

NPI: 1427770619
Provider Name (Legal Business Name): GAYLENE MARVIN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 02/21/2026
Certification Date: 02/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S LA CANADA DR STE 111
GREEN VALLEY AZ
85614-2600
US

IV. Provider business mailing address

601 W CAMINO CORTO
GREEN VALLEY AZ
85614-2762
US

V. Phone/Fax

Practice location:
  • Phone: 707-978-8220
  • Fax:
Mailing address:
  • Phone: 707-978-8220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-29782
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: