Provider Demographics
NPI:1952754905
Name:RICHARD, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:RICHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13442 HUNTINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3908
Mailing Address - Country:US
Mailing Address - Phone:909-697-9297
Mailing Address - Fax:909-899-9854
Practice Address - Street 1:13442 HUNTINGTON ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3908
Practice Address - Country:US
Practice Address - Phone:909-697-9297
Practice Address - Fax:909-899-9854
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72357104100000X
CA893361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker