Provider Demographics
NPI:1710767033
Name:GARDNER, GANNON AARON
Entity Type:Individual
Prefix:
First Name:GANNON
Middle Name:AARON
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51965 AVENIDA HERRERA
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-3166
Mailing Address - Country:US
Mailing Address - Phone:760-898-9106
Mailing Address - Fax:
Practice Address - Street 1:51965 AVENIDA HERRERA
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-3166
Practice Address - Country:US
Practice Address - Phone:760-898-9106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician