Provider Demographics
NPI:1245507946
Name:JOHNSON, GWENDOLYN (LPC)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:DR
Other - First Name:GWENDOLYN
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:3375 BILLY PL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-9318
Mailing Address - Country:US
Mailing Address - Phone:405-517-6369
Mailing Address - Fax:
Practice Address - Street 1:9212 N KELLEY AVE STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-2419
Practice Address - Country:US
Practice Address - Phone:405-242-5070
Practice Address - Fax:405-242-5071
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
OK5801101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKBGJ2011Medicaid