Provider Demographics
NPI:1740901594
Name:GARDNER, MARISSA (LSW)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8023
Mailing Address - Country:US
Mailing Address - Phone:815-522-1719
Mailing Address - Fax:
Practice Address - Street 1:734 POINTE DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8023
Practice Address - Country:US
Practice Address - Phone:815-522-1719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker