Provider Demographics
NPI:1275526832
Name:STINES, GWEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:
Last Name:STINES
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 1:307 S MAIN ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-3102
Mailing Address - Country:US
Mailing Address - Phone:574-523-3347
Mailing Address - Fax:574-296-7560
Practice Address - Street 1:307 S MAIN ST
Practice Address - Street 2:SUITE 305
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-3102
Practice Address - Country:US
Practice Address - Phone:574-523-3347
Practice Address - Fax:574-296-7560
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002493A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34002493AOtherLCSW LICENSE