Provider Demographics
NPI:1821895301
Name:GARDNER, MARTIN DANIEL (MA, QMHP-A, QIDP)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:DANIEL
Last Name:GARDNER
Suffix:
Gender:
Credentials:MA, QMHP-A, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-1219
Mailing Address - Country:US
Mailing Address - Phone:252-679-8084
Mailing Address - Fax:
Practice Address - Street 1:404 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-1219
Practice Address - Country:US
Practice Address - Phone:252-679-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251C00000XAgenciesDay Training, Developmentally Disabled Services