Provider Demographics
NPI:1194864330
Name:WORSHAM, GWENDOLYN
Entity Type:Individual
Prefix:MISS
First Name:GWENDOLYN
Middle Name:
Last Name:WORSHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 WOODRUFF
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006
Mailing Address - Country:US
Mailing Address - Phone:870-347-1436
Mailing Address - Fax:
Practice Address - Street 1:893 HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:AR
Practice Address - Zip Code:72006-5119
Practice Address - Country:US
Practice Address - Phone:870-347-5906
Practice Address - Fax:870-347-1457
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator