Provider Demographics
NPI:1669426946
Name:GARDNER, VONDA B (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:VONDA
Middle Name:B
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 COCKLE ST
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28445-6511
Mailing Address - Country:US
Mailing Address - Phone:910-231-1986
Mailing Address - Fax:
Practice Address - Street 1:743 COCKLE ST
Practice Address - Street 2:
Practice Address - City:SURF CITY
Practice Address - State:NC
Practice Address - Zip Code:28445-6511
Practice Address - Country:US
Practice Address - Phone:910-231-1986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0041001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002451Medicaid