Provider Demographics
NPI:1295219889
Name:GARDNER, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 MAYFIELD RD APT 406
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44118-5207
Mailing Address - Country:US
Mailing Address - Phone:614-597-9749
Mailing Address - Fax:
Practice Address - Street 1:22001 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44118-4819
Practice Address - Country:US
Practice Address - Phone:216-932-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2004972104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker