Provider Demographics
NPI:1962550087
Name:GWYN, TARA B (MS,CCC, SLP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:B
Last Name:GWYN
Suffix:
Gender:F
Credentials:MS,CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1508
Mailing Address - Country:US
Mailing Address - Phone:570-586-6046
Mailing Address - Fax:
Practice Address - Street 1:500 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1508
Practice Address - Country:US
Practice Address - Phone:570-586-6046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL-001077-L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist