Provider Demographics
NPI:1952824617
Name:GARDYNIK, ADELE XENIA
Entity Type:Individual
Prefix:
First Name:ADELE
Middle Name:XENIA
Last Name:GARDYNIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 W ALEXANDRINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2015
Mailing Address - Country:US
Mailing Address - Phone:313-831-5535
Mailing Address - Fax:
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:313-831-5535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011037231041C0700X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1952824617Medicaid