Healthcare Provider Details

I. General information

NPI: 1356519094
Provider Name (Legal Business Name): MEAGEN REA GUMM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911C N AZALEA ST STE C
VICTORIA TX
77901-4114
US

IV. Provider business mailing address

305 E GARDEN ST
GOLIAD TX
77963-4000
US

V. Phone/Fax

Practice location:
  • Phone: 361-645-9191
  • Fax:
Mailing address:
  • Phone: 361-645-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number41038
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number41038
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: