Provider Demographics
NPI:1255800231
Name:WHITE, GWEN MOCKLER (PSYD)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:MOCKLER
Last Name:WHITE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4617 WOODLAND AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3836
Mailing Address - Country:US
Mailing Address - Phone:267-254-0015
Mailing Address - Fax:
Practice Address - Street 1:4617 WOODLAND AVE FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-3836
Practice Address - Country:US
Practice Address - Phone:267-254-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016295103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist