Healthcare Provider Details

I. General information

NPI: 1932686102
Provider Name (Legal Business Name): GWENDYLON WEST BSW, MSW, QMHP,QIDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 OAKMAN BLVD STE C
DETROIT MI
48238-4019
US

IV. Provider business mailing address

PO BOX 15053
DETROIT MI
48215-0053
US

V. Phone/Fax

Practice location:
  • Phone: 313-961-4890
  • Fax:
Mailing address:
  • Phone: 313-377-0894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: