Provider Demographics
NPI:1497508592
Name:GARDNER, MARKITA REGINA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARKITA
Middle Name:REGINA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MARKITA
Other - Middle Name:R
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1435 BOGGS RD APT 218
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-2385
Mailing Address - Country:US
Mailing Address - Phone:202-680-2895
Mailing Address - Fax:
Practice Address - Street 1:2387 HUNTCREST WAY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8126
Practice Address - Country:US
Practice Address - Phone:678-710-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist