Basic Information
| Provider Information | |||||||||
| NPI: | 1902316987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOVETT | ||||||||
| FirstName: | GWEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | APCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUMBLE | ||||||||
| OtherFirstName: | GWEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 617 BAYONET CIR | ||||||||
| Address2: | |||||||||
| City: | MARINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939334600 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1141 HARBOR BAY PKWY STE 105 | ||||||||
| Address2: | |||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945026596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108352777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2017 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | 8252 | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.