Provider Demographics
NPI:1629220298
Name:BALDWIN, GWENNEVER ELAINE (LMT)
Entity Type:Individual
Prefix:MS
First Name:GWENNEVER
Middle Name:ELAINE
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:GWENNEVER
Other - Middle Name:ELAINE
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:827 MEADOW PL
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-3565
Mailing Address - Country:US
Mailing Address - Phone:770-640-6100
Mailing Address - Fax:
Practice Address - Street 1:1155 WOODSTOCK RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2231
Practice Address - Country:US
Practice Address - Phone:770-640-6100
Practice Address - Fax:770-640-0600
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000462225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist