Provider Demographics
NPI:1003037342
Name:GILLENSON, WENDY FAY (LICSW)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:FAY
Last Name:GILLENSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 FARQUHAR ST
Mailing Address - Street 2:#1
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1404
Mailing Address - Country:US
Mailing Address - Phone:617-327-8527
Mailing Address - Fax:
Practice Address - Street 1:95 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1524
Practice Address - Country:US
Practice Address - Phone:781-581-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1050321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical