Provider Demographics
NPI:1649474396
Name:SMITH-RUSSELL, GWENDOLYN L (LPC)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:L
Last Name:SMITH-RUSSELL
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 1:656 VISTA LN
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3332
Mailing Address - Country:US
Mailing Address - Phone:307-221-1133
Mailing Address - Fax:307-635-3965
Practice Address - Street 1:1613 EVANS AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4619
Practice Address - Country:US
Practice Address - Phone:307-221-1133
Practice Address - Fax:307-635-3965
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY147101YA0400X
WY423101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)