Healthcare Provider Details

I. General information

NPI: 1770018764
Provider Name (Legal Business Name): MARTIN GAUDIOSE LPCC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 EXECUTIVE DR
MARION OH
43302-6310
US

IV. Provider business mailing address

320 EXECUTIVE DR
MARION OH
43302-6310
US

V. Phone/Fax

Practice location:
  • Phone: 740-387-5210
  • Fax: 740-383-3472
Mailing address:
  • Phone: 740-387-5210
  • Fax: 740-383-3472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE1509
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: