Provider Demographics
NPI:1093228579
Name:HOLMAN-BARTON, GWENDOLYN RENEE (MS, MED)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:RENEE
Last Name:HOLMAN-BARTON
Suffix:
Gender:F
Credentials:MS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 J N PEASE PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4504
Mailing Address - Country:US
Mailing Address - Phone:980-395-7104
Mailing Address - Fax:
Practice Address - Street 1:1914 J N PEASE PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4504
Practice Address - Country:US
Practice Address - Phone:980-395-7104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X, 101Y00000X
NC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor