Provider Demographics
NPI:1700146164
Name:HARRISON, GWENDA MCCLAIN (LMT)
Entity Type:Individual
Prefix:
First Name:GWENDA
Middle Name:MCCLAIN
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15313 LIVINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-2819
Mailing Address - Country:US
Mailing Address - Phone:301-509-7249
Mailing Address - Fax:
Practice Address - Street 1:10903 INDIAN HEAD HWY
Practice Address - Street 2:SUITE 303
Practice Address - City:FT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4000
Practice Address - Country:US
Practice Address - Phone:301-509-7249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-19
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02737225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist