Healthcare Provider Details

I. General information

NPI: 1962669218
Provider Name (Legal Business Name): MS. DEIDRA AUBREY GWYTHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS DEBRA LYNN SMITH

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W B ST STE I
SPRINGFIELD OR
97477-4575
US

IV. Provider business mailing address

175 W B ST STE I
SPRINGFIELD OR
97477-4575
US

V. Phone/Fax

Practice location:
  • Phone: 541-988-1025
  • Fax: 541-844-1051
Mailing address:
  • Phone: 541-988-1025
  • Fax: 541-844-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: