Provider Demographics
NPI:1568087369
Name:GARDNER, MINNIE
Entity Type:Individual
Prefix:
First Name:MINNIE
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 1:1317 EAGLES TRACE PATH APT E
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-1113
Mailing Address - Country:US
Mailing Address - Phone:757-404-2967
Mailing Address - Fax:
Practice Address - Street 1:870 N MILITARY HWY STE 208
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3638
Practice Address - Country:US
Practice Address - Phone:757-627-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty