Provider Demographics
NPI:1295860195
Name:GARDNER, VIRGINIA ANN (MFT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:GINI
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:16 WOODLEAF CT
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-1325
Mailing Address - Country:US
Mailing Address - Phone:415-209-9454
Mailing Address - Fax:415-892-0318
Practice Address - Street 1:905 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1588
Practice Address - Country:US
Practice Address - Phone:415-339-8662
Practice Address - Fax:415-892-0318
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36879106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist