Provider Demographics
NPI:1154720266
Name:GARDINER, CARLY DAWN (AUD)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:DAWN
Last Name:GARDINER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MS
Other - First Name:CARLY
Other - Middle Name:DAWN
Other - Last Name:WIENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:2501 COTTONTAIL LN STE 105
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5125
Mailing Address - Country:US
Mailing Address - Phone:732-529-7120
Mailing Address - Fax:207-226-2064
Practice Address - Street 1:124 E MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3532
Practice Address - Country:US
Practice Address - Phone:316-482-1340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002522231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400146541Medicare PIN
NYG400302486Medicare PIN