Provider Demographics
NPI:1053855403
Name:BYNUM, GWENDOLYN (PLPC)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:BYNUM
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 OLIVER RD STE 4
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5757
Mailing Address - Country:US
Mailing Address - Phone:318-340-1535
Mailing Address - Fax:
Practice Address - Street 1:2101 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5045
Practice Address - Country:US
Practice Address - Phone:318-884-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9103101Y00000X, 101YP2500X
171M00000X, 251S00000X
LAPLC9103101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1306217062OtherMENTAL HEALTH