Provider Demographics
NPI:1467552752
Name:DR. LEORA GARDNER,PH.D.,P.A.
Entity Type:Organization
Organization Name:DR. LEORA GARDNER,PH.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEORA
Authorized Official - Middle Name:JOSEPHA
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-414-1640
Mailing Address - Street 1:8177 GLADES RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-4071
Mailing Address - Country:US
Mailing Address - Phone:561-414-1650
Mailing Address - Fax:
Practice Address - Street 1:8177 GLADES RD
Practice Address - Street 2:SUITE 215
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-4071
Practice Address - Country:US
Practice Address - Phone:561-414-1650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0005116103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59666Medicare ID - Type Unspecified