Provider Demographics
NPI:1720318082
Name:ROBERTS, GWENDOLYN LONG (LCMHC)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:LONG
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1603 COURTYARD E
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:NC
Mailing Address - Zip Code:28516-2438
Mailing Address - Country:US
Mailing Address - Phone:919-201-7124
Mailing Address - Fax:
Practice Address - Street 1:3332 BRIDGES ST STE 3A
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3296
Practice Address - Country:US
Practice Address - Phone:919-201-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-10
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7606101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health