Provider Demographics
NPI:1871017319
Name:GARDNER, KATHY (EDD, LMSW)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:EDD, LMSW
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 1491
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-1370
Mailing Address - Country:US
Mailing Address - Phone:602-505-0635
Mailing Address - Fax:
Practice Address - Street 1:37401 W BELLO LN
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-5069
Practice Address - Country:US
Practice Address - Phone:602-505-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AZLMSW-214441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty