Provider Demographics
NPI:1639462088
Name:GARDNER, DEBORAH ANN (LBSW)
Entity Type:Individual
Prefix:MISS
First Name:DEBORAH
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9660 CORNELL ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3428
Mailing Address - Country:US
Mailing Address - Phone:313-247-0596
Mailing Address - Fax:
Practice Address - Street 1:13575 LESURE
Practice Address - Street 2:STAR CENTER, INC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-3131
Practice Address - Country:US
Practice Address - Phone:313-493-4410
Practice Address - Fax:313-493-4415
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020793511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical