Provider Demographics
NPI:1235452772
Name:GADDIS, SHEENA BLAKE (MSW, LCSW, LISW-CP)
Entity Type:Individual
Prefix:MRS
First Name:SHEENA
Middle Name:BLAKE
Last Name:GADDIS
Suffix:
Gender:F
Credentials:MSW, LCSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 38TH AVE N # 207
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1313
Mailing Address - Country:US
Mailing Address - Phone:843-804-8200
Mailing Address - Fax:
Practice Address - Street 1:1229 38TH AVE N # 207
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:910-321-8817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0104301041C0700X
SC123441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical