Provider Demographics
NPI:1790102093
Name:GARDNER, CHARLES H JR (LADC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:H
Last Name:GARDNER
Suffix:JR
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:
Practice Address - Street 1:1012 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3060
Practice Address - Country:US
Practice Address - Phone:207-945-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC 5014101YA0400X
MEMC14888104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)