Provider Demographics
NPI:1285060970
Name:GARDNER, MIMI ELIZABETH
Entity type:Individual
Prefix:MS
First Name:MIMI
Middle Name:ELIZABETH
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MIMI
Other - Middle Name:ELIZABETH
Other - Last Name:GARDNER SUGGS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:7838 W FRANKFORT SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-9139
Mailing Address - Country:US
Mailing Address - Phone:815-464-1198
Mailing Address - Fax:
Practice Address - Street 1:2401 VALLEY DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2520
Practice Address - Country:US
Practice Address - Phone:219-413-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490053891041C0700X
IN34003903A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical