Provider Demographics
NPI:1861869307
Name:THOMASON, GWENA E (MED, LPC)
Entity type:Individual
Prefix:MRS
First Name:GWENA
Middle Name:E
Last Name:THOMASON
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13359 STATE HIGHWAY 155 S
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-6554
Mailing Address - Country:US
Mailing Address - Phone:903-266-1030
Mailing Address - Fax:903-705-6395
Practice Address - Street 1:13359 STATE HIGHWAY 155 S
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6554
Practice Address - Country:US
Practice Address - Phone:903-266-1030
Practice Address - Fax:903-705-6395
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17822101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional