Provider Demographics
NPI:1790086544
Name:BRAGG, GWENDOLYN MCCLELLAND
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:MCCLELLAND
Last Name:BRAGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2738 E 00 NS
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-6631
Mailing Address - Country:US
Mailing Address - Phone:765-860-2511
Mailing Address - Fax:
Practice Address - Street 1:2738 E 00 NS
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-6631
Practice Address - Country:US
Practice Address - Phone:765-860-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1071839101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool