Basic Information
| Provider Information | |||||||||
| NPI: | 1053855403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BYNUM | ||||||||
| FirstName: | GWENDOLYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 HUDSON LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712016068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185705400 | ||||||||
| FaxNumber: | 3185705403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 HUDSON LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185705400 | ||||||||
| FaxNumber: | 3185705403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2016 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1306217062 | 01 | LA | MENTAL HEALTH | OTHER |