Provider Demographics
NPI:1730410085
Name:YOUNG, GWENDA LOUISE (LPC)
Entity type:Individual
Prefix:
First Name:GWENDA
Middle Name:LOUISE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:GWENDA
Other - Middle Name:LOUISE
Other - Last Name:JARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:511 FORT ST RM 505
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3936
Mailing Address - Country:US
Mailing Address - Phone:810-966-0099
Mailing Address - Fax:810-696-7339
Practice Address - Street 1:511 FORT ST RM 505
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3936
Practice Address - Country:US
Practice Address - Phone:810-966-0099
Practice Address - Fax:810-696-7339
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010728101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382230613OtherFIN #