Provider Demographics
NPI:1396734836
Name:GARDENER, ANN MCKISSICK (LISW)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:MCKISSICK
Last Name:GARDENER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 CARLISLE NE BLVD.
Mailing Address - Street 2:#112
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-269-9187
Mailing Address - Fax:
Practice Address - Street 1:2921 CARLISLE BLVD NE
Practice Address - Street 2:#112
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-2865
Practice Address - Country:US
Practice Address - Phone:505-269-9187
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-25221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical