Healthcare Provider Details

I. General information

NPI: 1033925979
Provider Name (Legal Business Name): GWINN ALENE SPENCE LGCP, CAC-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RIVERSIDE DR
CROWNSVILLE MD
21032-1708
US

IV. Provider business mailing address

751 N RIVERSIDE DR
CROWNSVILLE MD
21032-1708
US

V. Phone/Fax

Practice location:
  • Phone: 443-871-0698
  • Fax:
Mailing address:
  • Phone: 443-871-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP15142
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberAC3321
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: