Provider Demographics
NPI:1598483455
Name:GARDNER PSYCHIATRY LLC
Entity Type:Organization
Organization Name:GARDNER PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:ORAWAN
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-303-9262
Mailing Address - Street 1:258 BRADLEY ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-1106
Mailing Address - Country:US
Mailing Address - Phone:203-303-9262
Mailing Address - Fax:860-672-1584
Practice Address - Street 1:258 BRADLEY ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-1106
Practice Address - Country:US
Practice Address - Phone:203-303-9262
Practice Address - Fax:860-672-1584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2023-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025219Medicaid