Healthcare Provider Details

I. General information

NPI: 1174079479
Provider Name (Legal Business Name): GWYN SCHUMACHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 CHICAGO ST
JAVA SD
57452
US

IV. Provider business mailing address

310 2ND AVE SE
ASHLEY ND
58413-7340
US

V. Phone/Fax

Practice location:
  • Phone: 605-649-6296
  • Fax:
Mailing address:
  • Phone: 701-228-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0627
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0627
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerSOUTH DAKOTA BOARD OF MEDICAL AND OSTEOPATHIC EXAMINERS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: