Provider Demographics
NPI:1902316987
Name:LOVETT, GWEN (APCC)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:LOVETT
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:HUMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:617 BAYONET CIR
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-4600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1141 HARBOR BAY PKWY STE 105
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94502-6596
Practice Address - Country:US
Practice Address - Phone:510-835-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA8252390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health