Healthcare Provider Details

I. General information

NPI: 1669668596
Provider Name (Legal Business Name): GWEN SELF WARREN L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 9TH ST
SHALLOWATER TX
79363-5127
US

IV. Provider business mailing address

1401 9TH ST
SHALLOWATER TX
79363-5127
US

V. Phone/Fax

Practice location:
  • Phone: 806-787-3686
  • Fax: 806-832-1336
Mailing address:
  • Phone: 806-787-3686
  • Fax: 806-832-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12031
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: