Provider Demographics
NPI:1851159289
Name:GWENDOLYN DEHORN LCSW LLC
Entity Type:Organization
Organization Name:GWENDOLYN DEHORN LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEHORN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:574-298-9708
Mailing Address - Street 1:300 S SAINT LOUIS BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3044
Mailing Address - Country:US
Mailing Address - Phone:574-245-3920
Mailing Address - Fax:
Practice Address - Street 1:300 S SAINT LOUIS BLVD STE 204
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3044
Practice Address - Country:US
Practice Address - Phone:574-245-3920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty