Provider Demographics
NPI:1962707570
Name:BLACKNELL, GWENDOLYN YVONNE (LCDC)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:YVONNE
Last Name:BLACKNELL
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 BROADWAY ST
Mailing Address - Street 2:APT. 3207
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77017-2320
Mailing Address - Country:US
Mailing Address - Phone:281-991-8668
Mailing Address - Fax:713-236-0120
Practice Address - Street 1:3207 BROADWAY ST
Practice Address - Street 2:APT. 3207
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77017-2320
Practice Address - Country:US
Practice Address - Phone:281-991-8668
Practice Address - Fax:713-236-0120
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10653101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)