Provider Demographics
NPI:1275045759
Name:FALLBROOKE, GWYN (LPCC)
Entity Type:Individual
Prefix:
First Name:GWYN
Middle Name:
Last Name:FALLBROOKE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:QUIN
Other - Middle Name:
Other - Last Name:FALLBROOKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:581 W 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3816
Mailing Address - Country:US
Mailing Address - Phone:510-842-0746
Mailing Address - Fax:
Practice Address - Street 1:581 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3816
Practice Address - Country:US
Practice Address - Phone:510-842-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5298101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health