Provider Demographics
NPI:1134756737
Name:GARDNER, MORGAN JEAN PETERSON (BCA BA)
Entity type:Individual
Prefix:MRS
First Name:MORGAN
Middle Name:JEAN PETERSON
Last Name:GARDNER
Suffix:
Gender:F
Credentials:BCA BA
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:JEAN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2353 BADGER STREET
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2302
Mailing Address - Country:US
Mailing Address - Phone:906-273-1121
Mailing Address - Fax:906-225-6706
Practice Address - Street 1:2353 BADGER STREET
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2302
Practice Address - Country:US
Practice Address - Phone:906-273-1121
Practice Address - Fax:906-225-6706
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI22159090657106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst