Provider Demographics
NPI:1396857694
Name:GARDNER, GEORGE L (MSW /LCSW)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MSW /LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4146 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1207
Mailing Address - Country:US
Mailing Address - Phone:510-482-1002
Mailing Address - Fax:510-482-1000
Practice Address - Street 1:4146 PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1207
Practice Address - Country:US
Practice Address - Phone:510-482-1002
Practice Address - Fax:510-482-1000
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 13421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherPSYCHOTHERAPY / CONSULT