MEDICARE: GWENDOLYN Y MCCLEOD

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1922286608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN Y MCCLEOD

Provider Business Mailing Address
First Line	:	7487 MOHAWK ST APT 39
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-3458
Country	:	US
Telephone Number	:	619-203-4525
Fax Number	:

Provider Business Practice Location Address
First Line	:	7487 MOHAWK ST APT 39
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-3458
Country	:	US
Telephone Number	:	619-203-4525
Fax Number	:

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

Provider Enumeration Date	:	02/05/2008
Last Update Date	:	02/05/2008

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