Provider Demographics
NPI:1578721817
Name:GARDNER, MARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N WABASH AVE
Mailing Address - Street 2:SUITE 1805
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-2406
Mailing Address - Country:US
Mailing Address - Phone:312-372-3322
Mailing Address - Fax:312-372-3326
Practice Address - Street 1:203 N WABASH AVE
Practice Address - Street 2:SUITE 1805
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-2406
Practice Address - Country:US
Practice Address - Phone:312-372-3322
Practice Address - Fax:312-372-3326
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004477103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical