Provider Demographics
NPI:1114062080
Name:BURNLEY, GWENDOLYN
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:
Last Name:BURNLEY
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 1:1504 LASSEN CT
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-4022
Mailing Address - Country:US
Mailing Address - Phone:415-756-1350
Mailing Address - Fax:
Practice Address - Street 1:1638 KIRKWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94124-2137
Practice Address - Country:US
Practice Address - Phone:415-671-1165
Practice Address - Fax:415-970-0438
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32037OtherINSYST STAFF ID NUMBER