Provider Demographics
NPI:1043702574
Name:MILLER, GWENDOLYN
Entity Type:Individual
Prefix:MISS
First Name:GWENDOLYN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 BRIGGS AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-4003
Mailing Address - Country:US
Mailing Address - Phone:646-228-5062
Mailing Address - Fax:
Practice Address - Street 1:CREATE INC
Practice Address - Street 2:73-75 LENOX AVE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026
Practice Address - Country:US
Practice Address - Phone:646-228-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral