Provider Demographics
NPI:1598191108
Name:GARDNER, PORTIA
Entity Type:Individual
Prefix:MS
First Name:PORTIA
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 1:2625 ZANKER RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-2130
Mailing Address - Country:US
Mailing Address - Phone:408-325-5100
Mailing Address - Fax:408-944-9114
Practice Address - Street 1:2625 ZANKER RD
Practice Address - Street 2:STE 200
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-2130
Practice Address - Country:US
Practice Address - Phone:408-325-5100
Practice Address - Fax:408-944-9114
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health