Provider Demographics
NPI:1548200462
Name:GARDNER, DOUGLAS EDWARD (LMSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:37634 ENTERPRISE CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3440
Mailing Address - Country:US
Mailing Address - Phone:248-553-0902
Mailing Address - Fax:248-553-2632
Practice Address - Street 1:37634 ENTERPRISE CT
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3440
Practice Address - Country:US
Practice Address - Phone:248-553-0902
Practice Address - Fax:248-553-2632
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT32220635011041C0700X
OHI15002311041C0700X
AL1999C1041C0700X
MSC67531041C0700X
MI68010915251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical