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NPI Code Detail

MEDICARE: TARA B. GWYN M.S.,CCC, SLP

MEDICARE: TARA B. GWYN M.S.,CCC, SLP
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
1235Z00000XSpeech-Language PathologistSL-001077-LPA

General Provider Information

NPI Number : 1962550087
Entity Type Code : Individual
Provider Name (Legal Business Name) : TARA B. GWYN M.S.,CCC, SLP
Provider Business Mailing Address
First Line : 500 SCHOOL ST
Second Line :
City : CLARKS SUMMIT
State : PA
Zip : 18411-1508
Country : US
Telephone Number : 570-586-6046
Fax Number :
Provider Business Practice Location Address
First Line : 500 SCHOOL ST
Second Line :
City : CLARKS SUMMIT
State : PA
Zip : 18411-1508
Country : US
Telephone Number : 570-586-6046
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/08/2007
Last Update Date : 07/08/2007

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