Provider Demographics
NPI:1891827002
Name:BAMMEL, GWENDOLYN LAURA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:LAURA
Last Name:BAMMEL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 SARATOGA DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2645
Mailing Address - Country:US
Mailing Address - Phone:248-457-0570
Mailing Address - Fax:
Practice Address - Street 1:271 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1637
Practice Address - Country:US
Practice Address - Phone:734-455-4095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010878231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical