Provider Demographics
NPI:1376903302
Name:GAVIN, MARJORIE
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:GAVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:
Other - Last Name:GAVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:680 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:502-596-7640
Mailing Address - Fax:
Practice Address - Street 1:1841 CRYSTAL FALLS PKWY
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-3330
Practice Address - Country:US
Practice Address - Phone:512-487-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109540225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist