MEDICARE: GWENDOLYN UPSHAW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	164W00000X	Licensed Practical Nurse	145673	OH

General Provider Information

NPI Number	:	1952952798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN UPSHAW

Provider Business Mailing Address
First Line	:	4123 GRACE ST
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2924
Country	:	US
Telephone Number	:	937-974-6277
Fax Number	:

Provider Business Practice Location Address
First Line	:	4123 GRACE ST
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2924
Country	:	US
Telephone Number	:	937-974-6277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	04/03/2026

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