Healthcare Provider Details

I. General information

NPI: 1871612770
Provider Name (Legal Business Name): MARYJO GAVIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 TRANSVERSE DR
TOLEDO OH
43614
US

IV. Provider business mailing address

3355 GLENDALE AVE FL 3
TOLEDO OH
43614-2426
US

V. Phone/Fax

Practice location:
  • Phone: 419-383-5695
  • Fax: 419-383-3031
Mailing address:
  • Phone: 419-383-5695
  • Fax: 419-383-3031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301011920
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP.4227
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: