Provider Demographics
NPI:1659405967
Name:SMITH, GWENDOLYN W (LPC)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:W
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-1027
Mailing Address - Country:US
Mailing Address - Phone:706-638-5580
Mailing Address - Fax:706-639-2041
Practice Address - Street 1:501 MIZE ST.
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728
Practice Address - Country:US
Practice Address - Phone:706-638-5580
Practice Address - Fax:706-639-2041
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional