Provider Demographics
NPI:1215762539
Name:GARDINER, DEJA LATRICE (BCBA)
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:LATRICE
Last Name:GARDINER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8330 WILLOW PLACE DR S APT 803
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4684
Mailing Address - Country:US
Mailing Address - Phone:281-615-1269
Mailing Address - Fax:
Practice Address - Street 1:12101 GRANT RD
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-2761
Practice Address - Country:US
Practice Address - Phone:281-223-5200
Practice Address - Fax:281-783-2839
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst