Provider Demographics
NPI:1518319946
Name:GARDNER, ALISA
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4966 EL CAMINO REAL
Mailing Address - Street 2:STE 224
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1458
Mailing Address - Country:US
Mailing Address - Phone:650-690-2362
Mailing Address - Fax:650-590-4938
Practice Address - Street 1:3151 AIRWAY AVE
Practice Address - Street 2:T2
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4607
Practice Address - Country:US
Practice Address - Phone:949-438-2342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-09
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW186151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical