Provider Demographics
NPI:1245237114
Name:DEHORN, GWENDOLYN C (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:C
Last Name:DEHORN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W ANGELA BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1101
Mailing Address - Country:US
Mailing Address - Phone:574-245-3920
Mailing Address - Fax:573-232-5386
Practice Address - Street 1:150 W ANGELA BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1101
Practice Address - Country:US
Practice Address - Phone:574-245-3920
Practice Address - Fax:573-232-5386
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003375101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34003375OtherSTATE LICENCE NUMBER
IN00000018781300OtherBLUE CROSS BLUE SHIELD
IN34003375OtherSTATE LICENCE NUMBER
M400021442Medicare PIN