Provider Demographics
NPI:1306977251
Name:GAYNES, MARIANN (MSW LCSW)
Entity type:Individual
Prefix:MS
First Name:MARIANN
Middle Name:
Last Name:GAYNES
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 BROOKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825
Mailing Address - Country:US
Mailing Address - Phone:203-330-6200
Mailing Address - Fax:
Practice Address - Street 1:361 BIRD ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605
Practice Address - Country:US
Practice Address - Phone:203-330-6000
Practice Address - Fax:203-576-8444
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00031011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800002019Medicare ID - Type UnspecifiedMEDICARE