Provider Demographics
NPI:1629579487
Name:GARDNER, DEIRDRE
Entity Type:Individual
Prefix:
First Name:DEIRDRE
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 1:768 SEAWALL RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:MD
Mailing Address - Zip Code:21221-3939
Mailing Address - Country:US
Mailing Address - Phone:443-839-3799
Mailing Address - Fax:
Practice Address - Street 1:768 SEAWALL RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-3939
Practice Address - Country:US
Practice Address - Phone:443-839-3799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD234011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical