Provider Demographics
NPI:1760689236
Name:GARDNER, MARY ELLEN (MSE-CD, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MSE-CD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 GLENMERE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7442
Mailing Address - Country:US
Mailing Address - Phone:501-499-0275
Mailing Address - Fax:
Practice Address - Street 1:320 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:AR
Practice Address - Zip Code:72006-2650
Practice Address - Country:US
Practice Address - Phone:870-347-2241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR442235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist