Provider Demographics
NPI:1760040018
Name:AUSTIN, GWENDOLYN (LAC)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HARDLEY ST
Mailing Address - Street 2:
Mailing Address - City:FORT HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613-1135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2030 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5905
Practice Address - Country:US
Practice Address - Phone:216-738-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16867101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health