Provider Demographics
NPI:1437373354
Name:GARDNER, LAQUITA RENEE (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAQUITA
Middle Name:RENEE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CHELSEA DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-1406
Mailing Address - Country:US
Mailing Address - Phone:318-548-1517
Mailing Address - Fax:
Practice Address - Street 1:120 BECKRICH RD
Practice Address - Street 2:SUITE 130
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2521
Practice Address - Country:US
Practice Address - Phone:850-235-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3016235Z00000X
FLSA 9400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist