Provider Demographics
NPI:1033925979
Name:SPENCE, GWINN ALENE (LGCP, CAC-AD)
Entity type:Individual
Prefix:
First Name:GWINN
Middle Name:ALENE
Last Name:SPENCE
Suffix:
Gender:F
Credentials:LGCP, CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1708
Mailing Address - Country:US
Mailing Address - Phone:443-871-0698
Mailing Address - Fax:
Practice Address - Street 1:751 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-1708
Practice Address - Country:US
Practice Address - Phone:443-871-0698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC3321103TA0400X
MDLGP15142101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)