Provider Demographics
NPI:1831213958
Name:GARDNER, CARTER CAMPBELL (PHD)
Entity type:Individual
Prefix:DR
First Name:CARTER
Middle Name:CAMPBELL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 SEATTLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1774
Mailing Address - Country:US
Mailing Address - Phone:619-627-7701
Mailing Address - Fax:619-644-5751
Practice Address - Street 1:4700 SPRING STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-0237
Practice Address - Country:US
Practice Address - Phone:619-627-7701
Practice Address - Fax:619-644-5751
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10888103TC1900X
CAPSY.10888101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
10888AMedicare PIN