Provider Demographics
NPI:1215107438
Name:BATHER-GARDNER, MELODY (MA, MISA II)
Entity type:Individual
Prefix:MS
First Name:MELODY
Middle Name:
Last Name:BATHER-GARDNER
Suffix:
Gender:F
Credentials:MA, MISA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3741
Mailing Address - Country:US
Mailing Address - Phone:312-572-4518
Mailing Address - Fax:312-572-4518
Practice Address - Street 1:2020 W HARRISON ST
Practice Address - Street 2:226
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3741
Practice Address - Country:US
Practice Address - Phone:312-572-4518
Practice Address - Fax:312-572-4518
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19258OtherIAODAPCA