Provider Demographics
NPI:1932322484
Name:GARDNER, JOHN C (ML-012201)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:GARDNER
Suffix:
Gender:M
Credentials:ML-012201
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 N STATE COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1361
Mailing Address - Country:US
Mailing Address - Phone:714-990-0700
Mailing Address - Fax:714-990-0142
Practice Address - Street 1:2228 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1361
Practice Address - Country:US
Practice Address - Phone:714-990-0700
Practice Address - Fax:714-990-0142
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAML-012201106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist