Provider Demographics
NPI:1285385138
Name:WORRALL, GYPSY TWILIGHT
Entity type:Individual
Prefix:MRS
First Name:GYPSY
Middle Name:TWILIGHT
Last Name:WORRALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-6452
Mailing Address - Country:US
Mailing Address - Phone:989-909-4269
Mailing Address - Fax:
Practice Address - Street 1:417 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6452
Practice Address - Country:US
Practice Address - Phone:989-909-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician