Provider Demographics
NPI:1518162254
Name:MILLAM, GWEN MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MARIE
Last Name:MILLAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3940 DREW AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1048
Mailing Address - Country:US
Mailing Address - Phone:612-251-5795
Mailing Address - Fax:
Practice Address - Street 1:11812 WAYZATA BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2012
Practice Address - Country:US
Practice Address - Phone:612-251-5795
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
MN166971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical