Provider Demographics
NPI:1093349755
Name:GIST, GWENDOLYN (MS/LSW)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:
Last Name:GIST
Suffix:
Gender:F
Credentials:MS/LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 WAVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-2231
Mailing Address - Country:US
Mailing Address - Phone:937-409-0045
Mailing Address - Fax:
Practice Address - Street 1:117 ASHWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-2643
Practice Address - Country:US
Practice Address - Phone:937-221-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator