Provider Demographics
NPI:1386044923
Name:GARDNER, RACHEL ANNE (PHD)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 GIFFORD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-1107
Mailing Address - Country:US
Mailing Address - Phone:585-204-7560
Mailing Address - Fax:
Practice Address - Street 1:10 W PULTENEY SQ STE 102
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1580
Practice Address - Country:US
Practice Address - Phone:585-204-7560
Practice Address - Fax:585-206-4903
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022851-1103T00000X
103TS0200X
56332103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05683858Medicaid