Provider Demographics
NPI:1689319485
Name:GARDNER, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
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 1:412 E 83RD ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-5507
Mailing Address - Country:US
Mailing Address - Phone:773-386-3113
Mailing Address - Fax:
Practice Address - Street 1:412 E 83RD ST APT 1B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-5507
Practice Address - Country:US
Practice Address - Phone:773-386-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114608104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker