Healthcare Provider Details

I. General information

NPI: 1588571806
Provider Name (Legal Business Name): GWENDOLYN DEVIVO LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38285 MURPHY CIR W
SELBYVILLE DE
19975-3420
US

IV. Provider business mailing address

38285 MURPHY CIR W
SELBYVILLE DE
19975-3420
US

V. Phone/Fax

Practice location:
  • Phone: 410-259-4103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP15865
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: