Provider Demographics
NPI:1174875538
Name:HOLEMAN, GWENDOLYN MARIE WYDRA (LCSW)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MARIE WYDRA
Last Name:HOLEMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:MARIE
Other - Last Name:WYDRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4200
Mailing Address - Country:US
Mailing Address - Phone:630-938-2727
Mailing Address - Fax:
Practice Address - Street 1:300 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-938-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2016-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490179551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical