Provider Demographics
NPI:1356956668
Name:JOHNSON, GWENDOLY DENISE (QP)
Entity type:Individual
Prefix:MS
First Name:GWENDOLY
Middle Name:DENISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-1177
Mailing Address - Country:US
Mailing Address - Phone:919-358-1204
Mailing Address - Fax:
Practice Address - Street 1:1915 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1177
Practice Address - Country:US
Practice Address - Phone:919-358-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No174400000XOther Service ProvidersSpecialist