Provider Demographics
NPI:1912379298
Name:BRIMBLE, GWENDOLYN (MA, MS LLP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:BRIMBLE
Suffix:
Gender:F
Credentials:MA, MS LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47818 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-3373
Mailing Address - Country:US
Mailing Address - Phone:586-323-3620
Mailing Address - Fax:
Practice Address - Street 1:47818 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-3373
Practice Address - Country:US
Practice Address - Phone:586-323-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014422103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical