MEDICARE: MS. GWENDOLYN W SMITH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW001967	GA

General Provider Information

NPI Number	:	1972668226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GWENDOLYN W SMITH LCSW

Provider Business Mailing Address
First Line	:	3633 WHEELER RD
Second Line	:	SUITE 110
City	:	AUGUSTA
State	:	GA
Zip	:	30909-6549
Country	:	US
Telephone Number	:	706-855-7784
Fax Number	:	706-651-1090

Provider Business Practice Location Address
First Line	:	3633 WHEELER RD
Second Line	:	SUITE 110
City	:	AUGUSTA
State	:	GA
Zip	:	30909-6549
Country	:	US
Telephone Number	:	706-855-7784
Fax Number	:	706-651-1090

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	07/08/2007

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