Provider Demographics
NPI:1215125968
Name:LO, GWENDOLYN (LCSW)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:LO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10929 SOUTH ST STE 208B
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-5368
Mailing Address - Country:US
Mailing Address - Phone:562-924-5526
Mailing Address - Fax:562-924-1040
Practice Address - Street 1:10929 SOUTH ST STE 208B
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703
Practice Address - Country:US
Practice Address - Phone:562-924-5526
Practice Address - Fax:562-924-1040
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 14829104100000X
CALCSW279061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAAD3392Medicaid