Provider Demographics
NPI:1457560625
Name:COLVIN, GWYNN S (LPC)
Entity type:Individual
Prefix:MS
First Name:GWYNN
Middle Name:S
Last Name:COLVIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4424
Mailing Address - Country:US
Mailing Address - Phone:912-403-1544
Mailing Address - Fax:
Practice Address - Street 1:1505 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4424
Practice Address - Country:US
Practice Address - Phone:912-403-1544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006222101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health