Provider Demographics
NPI:1417152257
Name:COLLINS, GWENDOLYN I (CLINICAL SOCIAL WORK)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:COLLINS
Suffix:I
Gender:F
Credentials:CLINICAL SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19166 MCINTYRE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1859
Mailing Address - Country:US
Mailing Address - Phone:313-531-2995
Mailing Address - Fax:313-531-9261
Practice Address - Street 1:26847 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-1544
Practice Address - Country:US
Practice Address - Phone:313-592-1765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010795261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical