Provider Demographics
NPI:1568636645
Name:BAULDRY, GWENN MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:GWENN
Middle Name:MARIE
Last Name:BAULDRY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 E BROADWAY
Mailing Address - Street 2:STE 420
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-221-8689
Mailing Address - Fax:
Practice Address - Street 1:132 E BROADWAY
Practice Address - Street 2:STE 420
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3158
Practice Address - Country:US
Practice Address - Phone:541-221-8689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10028225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist