Provider Demographics
NPI:1932842598
Name:GARDNER, TABATHA (LSW)
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:TABATHA
Other - Middle Name:
Other - Last Name:DESSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24727 ROUTE 6
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-8257
Mailing Address - Country:US
Mailing Address - Phone:570-265-0100
Mailing Address - Fax:
Practice Address - Street 1:24727 ROUTE 6
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-8257
Practice Address - Country:US
Practice Address - Phone:570-265-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW139226104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker