Provider Demographics
NPI:1508325218
Name:GOURDINE, SHEMIKA LUTWIANE
Entity Type:Individual
Prefix:MRS
First Name:SHEMIKA
Middle Name:LUTWIANE
Last Name:GOURDINE
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 1:1521 SHERWOOD FOREST ST APT 1508
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-3605
Mailing Address - Country:US
Mailing Address - Phone:832-434-6790
Mailing Address - Fax:832-409-6606
Practice Address - Street 1:1521 SHERWOOD FOREST ST APT 1508
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-3605
Practice Address - Country:US
Practice Address - Phone:832-434-6790
Practice Address - Fax:832-409-6606
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities