Provider Demographics
NPI:1386839231
Name:MOODY-TZANNES, GWENDOLYN ELIZABETH
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:ELIZABETH
Last Name:MOODY-TZANNES
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:GWENDOLYN
Other - Middle Name:ELIZABETH
Other - Last Name:TZANNES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:2500 BISSELL AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-1815
Mailing Address - Country:US
Mailing Address - Phone:925-323-0179
Mailing Address - Fax:
Practice Address - Street 1:2540 CHARLESTON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-2508
Practice Address - Country:US
Practice Address - Phone:510-531-7551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 52291106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist