Provider Demographics
NPI:1992826069
Name:GARDNER, REBECCA SMOOT (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SMOOT
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNNE
Other - Last Name:SMOOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 RUSKIN DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910
Mailing Address - Country:US
Mailing Address - Phone:719-572-6100
Mailing Address - Fax:719-572-6080
Practice Address - Street 1:179 PARKSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910
Practice Address - Country:US
Practice Address - Phone:719-572-6300
Practice Address - Fax:719-572-6399
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD116381041C0700X
CO15141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical