Provider Demographics
NPI:1982957858
Name:MUECKE GARDNER, LEE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:A
Last Name:MUECKE GARDNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 HARRIAD DR W
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1206
Mailing Address - Country:US
Mailing Address - Phone:516-384-3743
Mailing Address - Fax:
Practice Address - Street 1:818 HARRIAD DR W
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1206
Practice Address - Country:US
Practice Address - Phone:516-384-3743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009675103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical