Provider Demographics
NPI:1952391534
Name:GARDNER, PAULA MICHELLE (PSYD, HSPP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:MICHELLE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 W. SMITH VALLEY RD., #231
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-8511
Mailing Address - Country:US
Mailing Address - Phone:317-801-1218
Mailing Address - Fax:317-884-5518
Practice Address - Street 1:3209 W. SMITH VALLEY RD., #231
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-8511
Practice Address - Country:US
Practice Address - Phone:317-801-1218
Practice Address - Fax:317-884-5518
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041719A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200408260AMedicaid
IN000000225455OtherANTHEM
IN277180000OtherMAGELLAN