Provider Demographics
NPI:1255429122
Name:GARRETT, GWENDOLYN G (MAOTR)
Entity type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:G
Last Name:GARRETT
Suffix:
Gender:F
Credentials:MAOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:525 OYSTER POINT RD
Practice Address - Street 2:SUITE E
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-6014
Practice Address - Country:US
Practice Address - Phone:757-269-0430
Practice Address - Fax:757-269-0432
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119001200225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255429122Medicaid
VA7150820OtherAETNA
VA1154551935OtherBCBS (OCCUPATIONAL THERAPY)
VAP00733181OtherMEDICARE RAILROAD
VA7150820OtherAETNA
VAP00733181OtherMEDICARE RAILROAD