Provider Demographics
NPI:1346013794
Name:GWYNN, TYQWISHA (OTL)
Entity Type:Individual
Prefix:
First Name:TYQWISHA
Middle Name:
Last Name:GWYNN
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HORIZON DR STE 310
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2058 SPRING CREEK DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-6110
Practice Address - Country:US
Practice Address - Phone:919-667-5593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16393225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist