Provider Demographics
NPI:1275776759
Name:GANGWISH, VICKIE SUE (MSW)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:SUE
Last Name:GANGWISH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 PATHFINDER WAY
Mailing Address - Street 2:SUITE130
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3242
Mailing Address - Country:US
Mailing Address - Phone:321-639-1224
Mailing Address - Fax:321-639-1194
Practice Address - Street 1:1037 PATHFINDER WAY
Practice Address - Street 2:SUITE130
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3242
Practice Address - Country:US
Practice Address - Phone:321-639-1224
Practice Address - Fax:321-639-1194
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical