Provider Demographics
NPI:1659567550
Name:GARDNER, LAURIE JOANNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:JOANNE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-2123
Mailing Address - Country:US
Mailing Address - Phone:207-462-0596
Mailing Address - Fax:207-549-3198
Practice Address - Street 1:17 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:ME
Practice Address - Zip Code:04345-2123
Practice Address - Country:US
Practice Address - Phone:207-462-0596
Practice Address - Fax:207-549-3198
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC104061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431738699Medicaid