Provider Demographics
NPI:1013945229
Name:GARDNER, LAMAURICE H (PSYD)
Entity Type:Individual
Prefix:
First Name:LAMAURICE
Middle Name:H
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:313-576-1000
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 207
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007265103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F34976OtherBLUE CROSS MICHIGAN
MI0M59550Medicare ID - Type Unspecified