Provider Demographics
NPI:1407991722
Name:GARDNER, ELLEN JOAN (LICSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:JOAN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 GIFFORD DR
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-3536
Mailing Address - Country:US
Mailing Address - Phone:508-854-0617
Mailing Address - Fax:
Practice Address - Street 1:255 MAIN ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-4331
Practice Address - Country:US
Practice Address - Phone:978-343-6957
Practice Address - Fax:978-343-0449
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10208311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP06201Medicare ID - Type UnspecifiedMEDICARE PROVIDER