Provider Demographics
NPI:1982102489
Name:CUTLER, GWEN MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MARIE
Last Name:CUTLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:
Other - Last Name:MOA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:179 S MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1337
Mailing Address - Country:US
Mailing Address - Phone:208-339-4936
Mailing Address - Fax:
Practice Address - Street 1:163 E ELVA ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2233
Practice Address - Country:US
Practice Address - Phone:208-932-4493
Practice Address - Fax:208-932-4582
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-35142104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker