Provider Demographics
NPI:1730411638
Name:PHILLIPS, GWENDOLYN (MA, MCAP, IMH 9889)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA, MCAP, IMH 9889
Other - Prefix:MS
Other - First Name:GWENDOLYN
Other - Middle Name:PRENTINA
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1280 N CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-6377
Mailing Address - Country:US
Mailing Address - Phone:561-228-1598
Mailing Address - Fax:
Practice Address - Street 1:1280 N CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-6377
Practice Address - Country:US
Practice Address - Phone:561-228-1598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLADC-012635-2016101YA0400X
FLIMH 9889101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)