Provider Demographics
NPI:1952065765
Name:GARDNER, BONNY G II (MA)
Entity Type:Individual
Prefix:MISS
First Name:BONNY
Middle Name:G
Last Name:GARDNER
Suffix:II
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:BONNY
Other - Middle Name:G
Other - Last Name:GARDNER
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:1565 LONG POND RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4168
Mailing Address - Country:US
Mailing Address - Phone:585-723-7723
Mailing Address - Fax:
Practice Address - Street 1:1565 LONG POND RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4168
Practice Address - Country:US
Practice Address - Phone:585-723-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)