Provider Demographics
NPI:1043360639
Name:DAVIS, GWENDOLEN HAYDON (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLEN
Middle Name:HAYDON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:WENDY
Other - Middle Name:HAYDON
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1208 S KYLE WAY
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1928
Mailing Address - Country:US
Mailing Address - Phone:904-716-5619
Mailing Address - Fax:
Practice Address - Street 1:305 KINGSLEY LAKE DR
Practice Address - Street 2:SUITE 702
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3045
Practice Address - Country:US
Practice Address - Phone:904-716-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW76771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ074EOtherBCBS OUT OF NETWORK PROV
FL277216OtherMHN
FL061642215OtherINIDIVDUAL TAX ID
FL277216OtherMHN