Provider Demographics
NPI:1669668596
Name:WARREN, GWEN SELF (LPC)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:SELF
Last Name:WARREN
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 1:1401 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SHALLOWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79363-5127
Mailing Address - Country:US
Mailing Address - Phone:806-787-3686
Mailing Address - Fax:806-832-1336
Practice Address - Street 1:1401 9TH ST
Practice Address - Street 2:
Practice Address - City:SHALLOWATER
Practice Address - State:TX
Practice Address - Zip Code:79363-5127
Practice Address - Country:US
Practice Address - Phone:806-787-3686
Practice Address - Fax:806-832-1336
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12031101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional