Provider Demographics
NPI:1255595187
Name:GARDNER, TERA ANNE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:TERA
Middle Name:ANNE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3453
Mailing Address - Country:US
Mailing Address - Phone:651-266-7900
Mailing Address - Fax:651-266-7850
Practice Address - Street 1:1919 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3453
Practice Address - Country:US
Practice Address - Phone:651-266-7900
Practice Address - Fax:651-266-7850
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN174471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical