Provider Demographics
NPI:1982762399
Name:GARDNER, GLEN CHRISTIAN (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:CHRISTIAN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W CROSS DR
Mailing Address - Street 2:#250
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80123-2239
Mailing Address - Country:US
Mailing Address - Phone:303-904-3277
Mailing Address - Fax:303-904-7380
Practice Address - Street 1:9200 W CROSS DR
Practice Address - Street 2:#250
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-2239
Practice Address - Country:US
Practice Address - Phone:303-904-3277
Practice Address - Fax:303-904-7380
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO134231H00000X
CO407231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO801927Medicare PIN
CO801276Medicare PIN
COQ38597Medicare UPIN
CO801210Medicare PIN