Provider Demographics
NPI:1891368916
Name:HOLDER, GWENDOLYN LEE (LCADC, LPCA)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:LEE
Last Name:HOLDER
Suffix:
Gender:F
Credentials:LCADC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 CURTIS PIKE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-9794
Mailing Address - Country:US
Mailing Address - Phone:859-314-0365
Mailing Address - Fax:
Practice Address - Street 1:108 12TH ST
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:KY
Practice Address - Zip Code:40312-8979
Practice Address - Country:US
Practice Address - Phone:606-663-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY270741101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional