MEDICARE: MARNI GWYNN

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	C1347	OR

General Provider Information

NPI Number	:	1700925047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARNI GWYNN

Provider Business Mailing Address
First Line	:	80619 LOST CREEK RD
Second Line	:
City	:	DEXTER
State	:	OR
Zip	:	97431-9742
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1255 PEARL ST
Second Line	:	SUITE 102
City	:	EUGENE
State	:	OR
Zip	:	97401-3570
Country	:	US
Telephone Number	:	541-687-6983
Fax Number	:	541-687-2063

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/08/2007

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Directions to “ MARNI GWYNN ” Practice Location

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