Provider Demographics
NPI:1275817371
Name:KING, GWENDOLYN LAVONNE (CMT)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:LAVONNE
Last Name:KING
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 HARROW RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4234
Mailing Address - Country:US
Mailing Address - Phone:410-564-9898
Mailing Address - Fax:
Practice Address - Street 1:512 HARROW RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4234
Practice Address - Country:US
Practice Address - Phone:410-564-9898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019009875225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist