Provider Demographics
NPI:1578864468
Name:SMITH, GWENDOLYN DIANE (MSW)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 W EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6201
Mailing Address - Country:US
Mailing Address - Phone:408-523-3103
Mailing Address - Fax:408-733-6735
Practice Address - Street 1:2350 W EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-6201
Practice Address - Country:US
Practice Address - Phone:408-523-3103
Practice Address - Fax:408-733-6735
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical