Provider Demographics
NPI:1568611846
Name:DEWALT, GWENDOLYN D (RN, LBSW)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:D
Last Name:DEWALT
Suffix:
Gender:F
Credentials:RN, LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2761 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4105
Mailing Address - Country:US
Mailing Address - Phone:313-993-3964
Mailing Address - Fax:313-993-1372
Practice Address - Street 1:2761 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4105
Practice Address - Country:US
Practice Address - Phone:313-993-3964
Practice Address - Fax:313-993-1372
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704157517163W00000X
MI6802059768104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No104100000XBehavioral Health & Social Service ProvidersSocial Worker