Provider Demographics
NPI:1235911397
Name:CHICKALUSION, GWENDOLYNN STACY (COUNSELOR TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:GWENDOLYNN
Middle Name:STACY
Last Name:CHICKALUSION
Suffix:
Gender:F
Credentials:COUNSELOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2352
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-2352
Mailing Address - Country:US
Mailing Address - Phone:907-235-8001
Mailing Address - Fax:907-235-8099
Practice Address - Street 1:1230 OCEAN DR STE 1
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7911
Practice Address - Country:US
Practice Address - Phone:907-235-8319
Practice Address - Fax:907-235-8099
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5068101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)