Provider Demographics
NPI:1366007536
Name:SMITH, GWENDOLYN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13047
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70612-3047
Mailing Address - Country:US
Mailing Address - Phone:337-855-9023
Mailing Address - Fax:337-855-1829
Practice Address - Street 1:3535 KNIGHT LN TRLR 8
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-1233
Practice Address - Country:US
Practice Address - Phone:337-986-9197
Practice Address - Fax:337-588-4179
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL155131041C0700X
LA152351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical