Provider Demographics
NPI:1780915983
Name:SHORTER, GWENDOLYN SPANN (LISW, CP)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:SPANN
Last Name:SHORTER
Suffix:
Gender:F
Credentials:LISW, CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 ALBERT ST
Mailing Address - Street 2:PO BOX 282
Mailing Address - City:BISHOPVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29010-1202
Mailing Address - Country:US
Mailing Address - Phone:443-857-1248
Mailing Address - Fax:803-483-1410
Practice Address - Street 1:430 ALBERT ST
Practice Address - Street 2:410 CEDAR LN.
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010-1202
Practice Address - Country:US
Practice Address - Phone:443-857-1248
Practice Address - Fax:803-843-1410
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical