Provider Demographics
NPI:1124140959
Name:HOUSE, GWENDOLYN FISHER (PHD)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:FISHER
Last Name:HOUSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:FISHER
Other - Last Name:HOUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1945 PAULINE BLVD
Mailing Address - Street 2:SUITE 21-C
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5047
Mailing Address - Country:US
Mailing Address - Phone:734-213-1333
Mailing Address - Fax:734-994-1286
Practice Address - Street 1:1945 PAULINE BLVD
Practice Address - Street 2:SUITE 21-C
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5047
Practice Address - Country:US
Practice Address - Phone:734-213-1333
Practice Address - Fax:734-994-1286
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003783103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION50290Medicare ID - Type UnspecifiedPSYCHOLOGIST
MI62OH14615Medicare UPIN