Provider Demographics
NPI:1063127264
Name:GARDNER, KIMBERLY ANNE (LSW, CDP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LSW, CDP
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:86 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-2367
Mailing Address - Country:US
Mailing Address - Phone:781-535-7960
Mailing Address - Fax:
Practice Address - Street 1:1094 WORCESTER RD
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-5255
Practice Address - Country:US
Practice Address - Phone:508-628-6300
Practice Address - Fax:508-628-6301
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314037104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker