Provider Demographics
NPI:1164043113
Name:MARIE, GWENN NONE (BCPP, BCTMB, LMT)
Entity Type:Individual
Prefix:
First Name:GWENN
Middle Name:NONE
Last Name:MARIE
Suffix:
Gender:F
Credentials:BCPP, BCTMB, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 BROADWAY PL
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3620
Mailing Address - Country:US
Mailing Address - Phone:309-310-6472
Mailing Address - Fax:
Practice Address - Street 1:2416 E WASHINGTON ST STE A9
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-1612
Practice Address - Country:US
Practice Address - Phone:309-310-6472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.001257225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist