=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326547134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOUGHTWORK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2018
-----------------------------------------------------
Last Update Date | 02/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 178 NW GARDEN VALLEY BLVD
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-236-8733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 178 NW GARDEN VALLEY BLVD
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-236-8733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MAURICE CHARLES GUNYON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 541-236-8733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | L7344
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------