Provider Demographics
NPI:1831633189
Name:GARDNER, CLEVELAND EUGENE III
Entity type:Individual
Prefix:MR
First Name:CLEVELAND
Middle Name:EUGENE
Last Name:GARDNER
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4266 37TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1001
Mailing Address - Country:US
Mailing Address - Phone:858-285-9824
Mailing Address - Fax:
Practice Address - Street 1:4283 EL CAJON BLVD STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1289
Practice Address - Country:US
Practice Address - Phone:619-521-1743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor