Provider Demographics
NPI:1881678209
Name:GARDNER, LAURA JONES (MSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JONES
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4346 STARKEY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0605
Mailing Address - Country:US
Mailing Address - Phone:540-772-8043
Mailing Address - Fax:540-772-8242
Practice Address - Street 1:200 COUNTRY CLUB DR SW
Practice Address - Street 2:SUITE D-2
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-5400
Practice Address - Country:US
Practice Address - Phone:540-772-8043
Practice Address - Fax:540-772-8242
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040006991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008914648Medicaid
VA008914648Medicaid