Provider Demographics
NPI:1093067019
Name:ROSENBERG, GWENN (ND)
Entity Type:Individual
Prefix:DR
First Name:GWENN
Middle Name:
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:GWENN
Other - Middle Name:
Other - Last Name:ROSENBERG WILDMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ND
Mailing Address - Street 1:16 RIVERVIEW PL
Mailing Address - Street 2:
Mailing Address - City:QUAKER HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06375
Mailing Address - Country:US
Mailing Address - Phone:503-758-1878
Mailing Address - Fax:855-869-4891
Practice Address - Street 1:154 HEMPSTEAD ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-650-1030
Practice Address - Fax:855-869-4891
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000486175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12446377OtherCAQH