Provider Demographics
NPI:1225697055
Name:GARDNER, MICHAELA (MS, INTERN-SLP)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MS, INTERN-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:LOVELADY
Mailing Address - State:TX
Mailing Address - Zip Code:75851-0406
Mailing Address - Country:US
Mailing Address - Phone:936-222-3580
Mailing Address - Fax:
Practice Address - Street 1:19411 MCKAY DR STE 300
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-5713
Practice Address - Country:US
Practice Address - Phone:281-446-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115471235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist