Provider Demographics
NPI:1619046836
Name:DR. LEORA GARDNER,PH.D.,P.A.
Entity Type:Organization
Organization Name:DR. LEORA GARDNER,PH.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEORA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-414-1650
Mailing Address - Street 1:2600 N MILITARY TRL
Mailing Address - Street 2:SUITE 270
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6312
Mailing Address - Country:US
Mailing Address - Phone:561-414-1650
Mailing Address - Fax:561-241-4943
Practice Address - Street 1:2600 N MILITARY TRL
Practice Address - Street 2:SUITE 270
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6312
Practice Address - Country:US
Practice Address - Phone:561-414-1650
Practice Address - Fax:561-241-4943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0005116103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY0005116OtherLICENSE
FL59666Medicare ID - Type Unspecified