Provider Demographics
NPI:1720335946
Name:SAFRIET, GWEN (LCAS-P)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:SAFRIET
Suffix:
Gender:F
Credentials:LCAS-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 US HIGHWAY 17 S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9070
Mailing Address - Country:US
Mailing Address - Phone:252-702-8865
Mailing Address - Fax:
Practice Address - Street 1:1023 US HIGHWAY 17 S
Practice Address - Street 2:SUITE 1
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-9070
Practice Address - Country:US
Practice Address - Phone:252-702-8865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)