MEDICARE: ASK COACH GWEN , LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1114607850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASK COACH GWEN , LLC

Provider Business Mailing Address
First Line	:	660 ACOMA BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-3662
Country	:	US
Telephone Number	:	214-702-6775
Fax Number	:

Provider Business Practice Location Address
First Line	:	660 ACOMA BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-3662
Country	:	US
Telephone Number	:	214-702-6775
Fax Number	:

Authorized Official
Title or Position	:	CEO AND THERAPIST
Name	:	GWEN L HODRICK
Credential	:	LPC
Telephone Number	:	214-702-6775

Provider Enumeration Date	:	07/18/2023
Last Update Date	:	07/18/2023

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