Provider Demographics
NPI:1275197295
Name:GARDINER, GRACE A (LMHC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:GARDINER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5570 NE 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3314
Mailing Address - Country:US
Mailing Address - Phone:954-801-1777
Mailing Address - Fax:
Practice Address - Street 1:3800 W BROWARD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1018
Practice Address - Country:US
Practice Address - Phone:954-587-1008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16320101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health