Provider Demographics
NPI:1891819777
Name:GLATTHORN, GWEN A (LCAS,LCMHC)
Entity type:Individual
Prefix:MS
First Name:GWEN
Middle Name:A
Last Name:GLATTHORN
Suffix:
Gender:F
Credentials:LCAS,LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 LONG MEADOW CT APT 202
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3215
Mailing Address - Country:US
Mailing Address - Phone:215-970-3373
Mailing Address - Fax:
Practice Address - Street 1:211 E SIX FORKS RD STE 117
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7753
Practice Address - Country:US
Practice Address - Phone:215-970-3373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1055101YM0800X
NC4993101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1891819777Medicaid
NC6005246Medicaid