Provider Demographics
NPI:1467653220
Name:GARDNER, KAYLEA LYNN (BA)
Entity Type:Individual
Prefix:MS
First Name:KAYLEA
Middle Name:LYNN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 SE 133RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3555
Mailing Address - Country:US
Mailing Address - Phone:503-205-4334
Mailing Address - Fax:
Practice Address - Street 1:3415 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3371
Practice Address - Country:US
Practice Address - Phone:503-205-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool