Provider Demographics
NPI:1841524873
Name:HAUGEN, GWEN (LMT)
Entity type:Individual
Prefix:MS
First Name:GWEN
Middle Name:
Last Name:HAUGEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:797 MAYPORT RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BCH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3425
Mailing Address - Country:US
Mailing Address - Phone:904-382-1371
Mailing Address - Fax:
Practice Address - Street 1:797 MAYPORT RD
Practice Address - Street 2:
Practice Address - City:ATLANTIC BCH
Practice Address - State:FL
Practice Address - Zip Code:32233-3425
Practice Address - Country:US
Practice Address - Phone:904-382-1371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50965225700000X
FLMA51995225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270533998OtherEIN