Basic Information
| Provider Information | |||||||||
| NPI: | 1104322718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GADDIS | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CMHC (INTERN) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 W CLEVELAND ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336061881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273866495 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2002 W CLEVELAND ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336061881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273866495 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.