Provider Demographics
NPI:1073237178
Name:MARIEL GARDINER PSYCHOTHERAPY, PLLC
Entity Type:Organization
Organization Name:MARIEL GARDINER PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDINER
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:847-852-0994
Mailing Address - Street 1:1342 N CLEAVER ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1342 N CLEAVER ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2346
Practice Address - Country:US
Practice Address - Phone:847-852-0994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)