Provider Demographics
NPI:1326411737
Name:GARDNER, ROBIN R
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:R
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 1:550 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-2114
Mailing Address - Country:US
Mailing Address - Phone:631-852-1070
Mailing Address - Fax:631-852-1119
Practice Address - Street 1:970 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6110
Practice Address - Country:US
Practice Address - Phone:631-657-3920
Practice Address - Fax:631-657-3920
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083418-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical