Provider Demographics
NPI:1073336772
Name:GARDNER, KATIE JOANNA
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JOANNA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:KATIE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:20 SKYLARK DR APT 11
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 SKYLARK DR APT 11
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1250
Practice Address - Country:US
Practice Address - Phone:415-562-5957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-02
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147594106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist