Provider Demographics
NPI:1952048969
Name:CASEY-HINES, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:CASEY-HINES
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 1:2520 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2113
Mailing Address - Country:US
Mailing Address - Phone:318-868-3093
Mailing Address - Fax:318-868-3094
Practice Address - Street 1:2520 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2113
Practice Address - Country:US
Practice Address - Phone:318-868-3093
Practice Address - Fax:318-868-3094
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2304852Medicaid