Provider Demographics
NPI:1003904152
Name:GARDNER, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BOULDER CRESCENT ST
Mailing Address - Street 2:SUITE 203F
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3344
Mailing Address - Country:US
Mailing Address - Phone:719-660-5281
Mailing Address - Fax:
Practice Address - Street 1:10 BOULDER CRESCENT ST
Practice Address - Street 2:SUITE 203F
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3344
Practice Address - Country:US
Practice Address - Phone:719-660-5281
Practice Address - Fax:866-703-1432
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1820101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional