Provider Demographics
NPI:1194905620
Name:MASTERMAN, GWENDOLYN S (MOTR/L)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:S
Last Name:MASTERMAN
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1751
Mailing Address - Country:US
Mailing Address - Phone:304-842-9887
Mailing Address - Fax:304-842-9888
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1751
Practice Address - Country:US
Practice Address - Phone:304-842-9887
Practice Address - Fax:304-842-9888
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV920225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist