Provider Demographics
NPI:1790151561
Name:WHITTINGTON, GWENDOLYN (DPC, LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:
Last Name:WHITTINGTON
Suffix:
Gender:F
Credentials:DPC, LPC, NCC
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 2412
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-2412
Mailing Address - Country:US
Mailing Address - Phone:601-707-7176
Mailing Address - Fax:601-707-7292
Practice Address - Street 1:357 TOWNE CENTER BLVD., STE 203
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4837
Practice Address - Country:US
Practice Address - Phone:601-707-7176
Practice Address - Fax:601-707-7292
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1994101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional