Healthcare Provider Details

I. General information

NPI: 1265833495
Provider Name (Legal Business Name): MS. GWENDOLYN WRIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11457 SHOEMAKER ST
DETROIT MI
48213-3418
US

IV. Provider business mailing address

17153 JULIANA AVE
EASTPOINTE MI
48021-3081
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-3435
  • Fax:
Mailing address:
  • Phone: 586-746-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802080392
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: