Provider Demographics
NPI:1821559576
Name:GARDNER, KENNETH EDWARD (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWARD
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:MR
Other - First Name:KENNETH
Other - Middle Name:EDWARD
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYCHOLOGIST
Mailing Address - Street 1:30665 NORTHWESTERN HWY STE 255
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3144
Mailing Address - Country:US
Mailing Address - Phone:248-802-7713
Mailing Address - Fax:
Practice Address - Street 1:30665 NORTHWESTERN HWY STE 255
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3144
Practice Address - Country:US
Practice Address - Phone:248-802-7713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007852103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty