Provider Demographics
NPI:1790095834
Name:GARDNER, ELIZABETH (LMSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2181 ENGLESIDE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6224
Mailing Address - Country:US
Mailing Address - Phone:616-240-6668
Mailing Address - Fax:
Practice Address - Street 1:1550 E BELTLINE AVE SE STE 255
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4362
Practice Address - Country:US
Practice Address - Phone:616-947-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6801090857101YM0800X
MI68010908571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical