Provider Demographics
NPI:1396933115
Name:JAMES, GWENETTE MAURELL (LISW-S)
Entity type:Individual
Prefix:MRS
First Name:GWENETTE
Middle Name:MAURELL
Last Name:JAMES
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30799 PINETREE RD # 240
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5903
Mailing Address - Country:US
Mailing Address - Phone:216-799-7559
Mailing Address - Fax:
Practice Address - Street 1:29339 EUCLID AVE STE 102
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1985
Practice Address - Country:US
Practice Address - Phone:216-799-7559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS28637104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0158309Medicaid