Provider Demographics
NPI:1922286608
Name:MCCLEOD, GWENDOLYN Y
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:Y
Last Name:MCCLEOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7487 MOHAWK ST APT 39
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-3458
Mailing Address - Country:US
Mailing Address - Phone:619-203-4525
Mailing Address - Fax:
Practice Address - Street 1:7487 MOHAWK ST APT 39
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3458
Practice Address - Country:US
Practice Address - Phone:619-203-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)