Provider Demographics
NPI:1164520185
Name:GARDINER, DONALD T (LCSWR)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:T
Last Name:GARDINER
Suffix:
Gender:M
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 HERITAGE LANDING DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9378
Mailing Address - Country:US
Mailing Address - Phone:315-472-7885
Mailing Address - Fax:315-472-2513
Practice Address - Street 1:5800 HERITAGE LANDING DR
Practice Address - Street 2:SUITE E
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9378
Practice Address - Country:US
Practice Address - Phone:315-472-7885
Practice Address - Fax:315-472-2513
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34577R1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY56253CMedicare ID - Type Unspecified