Provider Demographics
NPI:1215130091
Name:ANDERSON, GWENELLYN (EDD)
Entity type:Individual
Prefix:DR
First Name:GWENELLYN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 HIGH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4446
Mailing Address - Country:US
Mailing Address - Phone:503-585-2856
Mailing Address - Fax:
Practice Address - Street 1:3000 MARKET ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1882
Practice Address - Country:US
Practice Address - Phone:503-910-7372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor