MEDICARE: GAYLE M JOLL-TAVERNIER LSW

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	101YM0800X	Mental Health Counselor	33008594A	IN

General Provider Information

NPI Number	:	1487208716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAYLE M JOLL-TAVERNIER LSW

Provider Business Mailing Address
First Line	:	7418 N 300 W
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9710
Country	:	US
Telephone Number	:	219-336-5557
Fax Number	:

Provider Business Practice Location Address
First Line	:	7418 N 300 W
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9710
Country	:	US
Telephone Number	:	219-336-5557
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	07/25/2019

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