Provider Demographics
NPI:1235502907
Name:WALTHES, GWENDOLYN MARIE
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MARIE
Last Name:WALTHES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:MARIE
Other - Last Name:MUSTARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:123 BRIGHTWOOD TER
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23690-3518
Mailing Address - Country:US
Mailing Address - Phone:757-343-8544
Mailing Address - Fax:
Practice Address - Street 1:123 BRIGHTWOOD TER
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23690-3518
Practice Address - Country:US
Practice Address - Phone:757-343-8544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006367101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor