Provider Demographics
NPI:1225295918
Name:WASHINGTON, GWENDOLYN M
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:M
Last Name:WASHINGTON
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 1:8050 STILLMIST DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-7430
Mailing Address - Country:US
Mailing Address - Phone:910-200-4840
Mailing Address - Fax:
Practice Address - Street 1:8050 STILLMIST DR
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-7430
Practice Address - Country:US
Practice Address - Phone:910-200-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2889235Z00000X, 314000000X
GASLP008494235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility