Healthcare Provider Details

I. General information

NPI: 1235452772
Provider Name (Legal Business Name): SHEENA BLAKE GADDIS MSW, LCSW, LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 38TH AVE N # 207
MYRTLE BEACH SC
29577
US

IV. Provider business mailing address

1229 38TH AVE N # 207
MYRTLE BEACH SC
29577-1313
US

V. Phone/Fax

Practice location:
  • Phone: 910-321-8817
  • Fax:
Mailing address:
  • Phone: 843-804-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC010430
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12344
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: