Provider Demographics
NPI:1780842211
Name:MCLEAN, GWENDOLYN CAROLINE (LIC AC)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:CAROLINE
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:133 ELM ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1405
Mailing Address - Country:US
Mailing Address - Phone:617-803-5636
Mailing Address - Fax:
Practice Address - Street 1:2 MAIN ST
Practice Address - Street 2:FOREVER YOUNG SKIN CARE AND MEDICAL DAY SPA
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-6100
Practice Address - Country:US
Practice Address - Phone:781-665-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-31
Last Update Date:2008-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227943171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist