Provider Demographics
NPI:1972652006
Name:GARDNER, HAROLD LAMAR JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:LAMAR
Last Name:GARDNER
Suffix:JR
Gender:M
Credentials:PHD
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 211008
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30917-1008
Mailing Address - Country:US
Mailing Address - Phone:706-860-1122
Mailing Address - Fax:706-860-3839
Practice Address - Street 1:3990 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2220
Practice Address - Country:US
Practice Address - Phone:706-860-1122
Practice Address - Fax:706-860-3839
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000488103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00083663AMedicaid
GA00083663AMedicaid