Provider Demographics
NPI:1407819261
Name:GARDNER, JR., JAMES ALLAN (PHD LICSW)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ALLAN
Last Name:GARDNER, JR.
Suffix:
Gender:M
Credentials:PHD LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 OAK ST
Mailing Address - Street 2:CB6
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1359
Mailing Address - Country:US
Mailing Address - Phone:617-268-1700
Mailing Address - Fax:617-268-1991
Practice Address - Street 1:58 OLD COLONY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2406
Practice Address - Country:US
Practice Address - Phone:617-268-1700
Practice Address - Fax:617-268-1991
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1069521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAGAP23688Medicare UPIN