Provider Demographics
NPI:1497988141
Name:CLARK, GWENDOLYN MARIE
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-5936
Mailing Address - Country:US
Mailing Address - Phone:720-244-0340
Mailing Address - Fax:
Practice Address - Street 1:2651 S HIGH ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5936
Practice Address - Country:US
Practice Address - Phone:720-244-0340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor