Provider Demographics
NPI:1346676848
Name:GWENANDREWS HOME OF SUCCESS AGENCY, INC.
Entity Type:Organization
Organization Name:GWENANDREWS HOME OF SUCCESS AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EREKA
Authorized Official - Middle Name:ANDREWS
Authorized Official - Last Name:REDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-875-0075
Mailing Address - Street 1:116 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-2411
Mailing Address - Country:US
Mailing Address - Phone:850-875-0075
Mailing Address - Fax:850-627-2614
Practice Address - Street 1:116 N MADISON ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-2411
Practice Address - Country:US
Practice Address - Phone:850-875-0075
Practice Address - Fax:850-627-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL691333496385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691333496Medicaid
FL002214300Medicaid