Provider Demographics
NPI:1851870331
Name:EDMOND, GWENDOLYN T (LPC)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:T
Last Name:EDMOND
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 BELLEVUE RD STE B
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2952
Mailing Address - Country:US
Mailing Address - Phone:478-274-3012
Mailing Address - Fax:478-274-7948
Practice Address - Street 1:103 MERCER DR STE B
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-4257
Practice Address - Country:US
Practice Address - Phone:478-274-3012
Practice Address - Fax:478-274-7948
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004269101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional