Provider Demographics
NPI:1912127770
Name:FARNSWORTH, GWEN (LCPC)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:
Last Name:FARNSWORTH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FORT MISSOULA # 10
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7203
Mailing Address - Country:US
Mailing Address - Phone:406-728-6065
Mailing Address - Fax:
Practice Address - Street 1:30 FORT MISSOULA # 10
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7203
Practice Address - Country:US
Practice Address - Phone:406-728-6065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT588174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT254345Medicaid