Provider Demographics
NPI:1902454127
Name:BEARD, GWENDOLYN (PSYD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:BEARD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 POPLAR AVE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4607
Mailing Address - Country:US
Mailing Address - Phone:901-287-5674
Mailing Address - Fax:901-287-6804
Practice Address - Street 1:848 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2816
Practice Address - Country:US
Practice Address - Phone:901-287-5674
Practice Address - Fax:901-287-6804
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3610103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ053006Medicaid
MS03001506Medicaid