Provider Demographics
NPI:1356832497
Name:GARDNER, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
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 1:503 FARRELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41012-2680
Mailing Address - Country:US
Mailing Address - Phone:859-578-3292
Mailing Address - Fax:859-578-3242
Practice Address - Street 1:513 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-1505
Practice Address - Country:US
Practice Address - Phone:859-331-3292
Practice Address - Fax:859-534-2989
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2550791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical