Provider Demographics
NPI:1174037691
Name:GAVIN, WINDY (MS)
Entity type:Individual
Prefix:
First Name:WINDY
Middle Name:
Last Name:GAVIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9302
Mailing Address - Country:US
Mailing Address - Phone:239-275-3222
Mailing Address - Fax:
Practice Address - Street 1:2789 ORTIZ AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905
Practice Address - Country:US
Practice Address - Phone:239-691-4487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 104100000X
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid