Healthcare Provider Details

I. General information

NPI: 1306828637
Provider Name (Legal Business Name): MARILYN A GRYTE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 ELLSWORTH ST SW
ALBANY OR
97321-2362
US

IV. Provider business mailing address

425 ELLSWORTH ST SW
ALBANY OR
97321-2362
US

V. Phone/Fax

Practice location:
  • Phone: 541-791-9164
  • Fax:
Mailing address:
  • Phone: 541-791-9164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC0907
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: