Healthcare Provider Details

I. General information

NPI: 1992911234
Provider Name (Legal Business Name): GWENDOLYN MODDRELL MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 W MAIN ST # B
SWAINSBORO GA
30401-3163
US

IV. Provider business mailing address

247 W MAIN ST # B
SWAINSBORO GA
30401-3163
US

V. Phone/Fax

Practice location:
  • Phone: 478-237-8101
  • Fax: 478-237-8118
Mailing address:
  • Phone: 478-237-8101
  • Fax: 478-237-8118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: GWENDOLYN MODDRELL
Title or Position: OWNER
Credential: MD
Phone: 478-237-8101