Provider Demographics
NPI:1275171217
Name:BLACKNALL, GWENDOLYN MARCELLA (LGADC)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:MARCELLA
Last Name:BLACKNALL
Suffix:
Gender:F
Credentials:LGADC
Other - Prefix:MRS
Other - First Name:KARINA
Other - Middle Name:
Other - Last Name:FONTANEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:65 DUKE ST
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-6128
Mailing Address - Country:US
Mailing Address - Phone:443-404-5751
Mailing Address - Fax:
Practice Address - Street 1:65 DUKE ST STE 203
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-6128
Practice Address - Country:US
Practice Address - Phone:443-824-4818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGA2466101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)