Provider Demographics
NPI:1528387271
Name:GARDNER, TYRA S
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:S
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 1:5811 WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:224 KAMEHAMEHA AVE # 201
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2860
Practice Address - Country:US
Practice Address - Phone:215-485-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor