Provider Demographics
NPI:1689149916
Name:GARDNER, KAREN (MED, BCBA)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1452 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-1614
Mailing Address - Country:US
Mailing Address - Phone:805-235-3093
Mailing Address - Fax:
Practice Address - Street 1:5900 ENTRADA AVE
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4231
Practice Address - Country:US
Practice Address - Phone:805-235-3093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-13
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-31795103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst