Provider Demographics
NPI:1124152467
Name:GARDNER, SALLY (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 SE TENINO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6751
Mailing Address - Country:US
Mailing Address - Phone:502-233-3042
Mailing Address - Fax:
Practice Address - Street 1:1725 SE TENINO ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6751
Practice Address - Country:US
Practice Address - Phone:502-233-3042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL22581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR85619000Medicare UPIN