Provider Demographics
NPI:1811451214
Name:GARDNER, CHEYENNE ROSE LEE
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:ROSE LEE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8924 W LONG LAKE RD LOT 49
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-9354
Mailing Address - Country:US
Mailing Address - Phone:989-306-5475
Mailing Address - Fax:
Practice Address - Street 1:8924 W LONG LAKE RD LOT 49
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-9354
Practice Address - Country:US
Practice Address - Phone:989-306-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst