Provider Demographics
NPI:1114394822
Name:GARDNER-MORIN, DANIEL (LPN)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:GARDNER-MORIN
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6309 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207
Mailing Address - Country:US
Mailing Address - Phone:313-921-4700
Mailing Address - Fax:313-921-9247
Practice Address - Street 1:6309 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207
Practice Address - Country:US
Practice Address - Phone:313-921-4700
Practice Address - Fax:313-921-9247
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703113193251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health