Provider Demographics
NPI:1518605971
Name:HERTRICK, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:HERTRICK
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 1:1634 SYCAMORE LINE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4132
Mailing Address - Country:US
Mailing Address - Phone:419-626-9156
Mailing Address - Fax:
Practice Address - Street 1:5339 HARTLAND CENTER RD
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:OH
Practice Address - Zip Code:44826-9738
Practice Address - Country:US
Practice Address - Phone:724-417-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH180743101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)