Provider Demographics
NPI:1467065763
Name:EASLEY, GWENDOLYN MARCIA
Entity Type:Individual
Prefix:MISS
First Name:GWENDOLYN
Middle Name:MARCIA
Last Name:EASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:GWENDOLYN
Other - Middle Name:MARCIA
Other - Last Name:EASLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1845 BUSINESS CENTER DR STE 106
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3447
Mailing Address - Country:US
Mailing Address - Phone:909-534-8290
Mailing Address - Fax:
Practice Address - Street 1:1845 BUSINESS CENTER DR STE 106
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3447
Practice Address - Country:US
Practice Address - Phone:909-534-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor